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COPYRIGHT DEPOSIT 




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Sat i Francisco, Cal. 



Family Medical 
Book 



MORALITY, THE DISEASES OF WOMEN 
AND CHILDREN, AND MISCEL- 
LANEOUS DISEASES 



Mrs. Malinda Goldson, M. D. 



ILLUSTRATED 



PACIFIC PRESS PUBLISHING COMPANY 
Oakland, California 



901 



TH* LIBRA** OF 
TwoCoP««e R«otwo> 

JAN. 22 1902 

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tort ft 






COPYRIGHT, BY MALINDA GOLDSON 



All Rights Reserved. 



4- ....:- IS:!....'.^ 



DEDICATED, WITH ... w AEE^CTlOXATE KEGARDS, 

TO 

OUE AMERICAN WOMEK 

Dr. Goldson is a specialist on the diseases of women. The authoi 
took the postgraduate course in London, England, in 1890, on the 
Diseases of Women and Children ; studied therapeutical electricity 
with the well-known French specialist in electricity, Dr. George Apos- 
toli, of Paris, France ; in 1892 opened the Lakeside Sanatorium in 
Oakland, California, conducted it successfully till 1897; in 1898 
entered upon a special medical missionary work for the benefit of her 
sex. 

The Author. 



PKEFACE. 

In view of the innocent-thinking women of America, the author 
has written this book for the sole purpose of explaining to them why 
that which is thought to be innocent is a criminal wrong that can not 
be denied. The author has endeavored to make this book a safe 
guide for women. 

We trust that our young women physicians will take a lively 
interest in this special line of medical missionary work ; that this 
national evil may be overcome. 

The author hopes that the introductory pages will be read with 
interest, because our American women will have need to raise men 
to defend our beloved country from any invasion that might be 
attempted by other foreign nations. 

For the preparation of the index special thanks are due to Prof. 
George Underwood, whose painstaking accuracy is evident. 

Malinda Goldso^ M. D. 



CONTENTS 

CHAPTER I. 
Introductory 17-28 

CHAPTER IT. 
General Diseases of Women and Clinical History of Cases 29-36 

CHAPTER III. 

Inflammations of the Female Genital Organs 37-61 

CHAPTER IV. 
Inflammations of the Uterine Appendages and Peritoneum 62-97 

CHAPTER V. 
Displacements of the Uterus 98-123 

CHAPTER VI. 

Functional Diseases — Disorders of the Uterine Functions. . . .121-155 

CHAPTER VII. 

Diseases of the Nervous System Dependent upon Disorders of 

the Pelvic Organs 156-161 

CHAPTER VIII. 
Insanity 165-173 

CHAPTER IX. 

Female Urethra and Its Diseases 171-181 

CHAPTER X. 

Diseases of the Bladder 185-203 

CHAPTER XL 

Diseases of the Rectum and Anus 201-249 

(11) 



1 2 Contents. 

CHAPTER XII. 
Diseases of the Female Breasts 250-255 

CHAPTER XIII. 

Diagnosis of Children's Diseases 256-272 

CHAPTER XIV. 

Diagnosis of Children's Diseases (Continued) 273-292 

CHAPTER XV. 
Maternal Impressions 293-303 

CHAPTER XVI. 
Diseases of the Foetus 304-312 

CHAPTER XVII. 

The Care of the Child at Birth, in Abnormal Conditions 313-320 

CHAPTER XVIII. 
Injuries of the New-born 321-328 

CHAPTER XIX. 

, Infant Feeding; Weaning 329-354 

CHAPTER XX. 
Wet-nurses 355-358 

CHAPTER XXI. 
Diet after Weaning 359-368 

CHAPTER XXII. 
Nursery Hygiene 369-379 

CHAPTER XXIII. 
Dentition 380-389 

CHAPTER XXIV. 

Puberty; Its Pathology and Hygiene 390-420 



Contents. 13 

CHAPTER XXV. 

Fevers and Miasmatic Diseases 421-434 

CHAPTEK XXVI. 
Simple Continued Fever 435-436 

CHAPTER XXVII. 
Thermic Fever; Heat Stroke; Insulation 437-440 

CHAPTER XXVIII. 
Enteric or Typhoid Fever 441-473 

CHAPTER XXIX. 
Typhus Fever 474-478 

CHAPTER XXX. 
Relapsing Fever 479-481 

CHAPTER XXXI. 

Cerebro-Spinal Meningitis (Spotted Fever) 482-490 

CHAPTER XXXII. 
Scarlet Fever 491-499 

CHAPTER XXXIII. 
Diphtheria • 500-510 

CHAPTER XXXIV. 

Causes of Ear Troubles in Children 511-514 

CHAPTER XXXV. 
Measles 515-520 

CHAPTER XXXVI. 
Rubella (Rothelu), German Measles 521-524 

CHAPTER XXXVII. 

Varicella (Chickenpox) 525-528 



14 Contents. 

CHAPTEK XXXVIII. 
Variola (Smallpox) 529-538 

CHAPTEK XXXIX. 

Pertussus ( Whooping-Cough) 539-545 

CHAPTEK XL. 
Parotitis (Mumps) 546-547 

CHAPTEK XLI. 
Erysipelas 548-553 

CHAPTER XLII. 
Rheumatism . 554-571 

CHAPTER XLIII. 
Cholera, or Cholera Asiatica 572-580 

CHAPTER XLIV. 
Malaria 581-592 

CHAPTER XLV. 
Yellow Fever 593-597 

CHAPTER XLVL 
Dengue (Breakhone Fever) 598-600 

CHAPTER XLVII. 
Xursing of Sick Children 601-612 

CHAPTER XLVIII. 
Diarrhea 613-627 

CHAPTER XLIX. 
Cholera Infantum 628-639 

CHAPTER L. 
Chronic Membranous Enteritis 640-644 



Contents. 15 

CHAPTER LI. 
Jaundice (Icterus) 645-649 

CHAPTER LIE 
Diseases of the Biliary Ducts 650-651 

4 

CHAPTER LIII. 
Acute and Chronic Constipation in Children 652-661 

CHAPTER LIT. 

Parasites of the Intestinal Canal, and Diseases Due to Parasites 

662-673 

CHAPTER LV. 
Maternity 674-705 

CHAPTER LVI. 
Nasal Obstruction 706-711 

CHAPTER LVII. 

Rhinitis (Xasal Catarrh) 712-71 ( .> 

CHAPTER LVIII. 
The Skin 720-727 

CHAPTER LIX. 
Erythema ! 728-758 

CHAPTER LX. 
Parasitic Diseases 759-764 

CHAPTER LXI. 
Poisons and Their Antidotes 765-769 

CHAPTER LXIL 
Eractures 770-790 

CHAPTER LXIII. 

Sprains, Contusions, Wounds, and Injuries of Joints 791-7 , .><; 



16 Contorts. 

CHAPTEE LXIV. 
Dislocations 79 r-815 

CHAPTEE LXV. 

Foods and Food Preparations 81 6-823 

CHAPTEE LXYI. 
Force Production — Energy from Food 824-851 

CHAPTEE LXVII. 
Sick-room Dietary 852-859 

CHAPTEE LXVIIL 

Asthma, Colds, Hay-fever, Tonsillitis S('»0-S(',s 



FAMILY MEDICAL BOOK 



CHAPTER I. 
INTRODUCTORY. 

DEDICATED TO OUR WOMEX. 

We feel the importance of our women being made aware of the 
causes of so much ill health prevailing among them, also among our 
children in early life. 

There are special growing evils and moral errors prevailing 
among our Anglo-Saxon people, which, apparently, would not be 
expedient for the ministers to treat from their pulpits. Neither can 
there be laws enacted by the means of which these growing evils can 
be checked. Hence the medical fraternity deem it to be the duty of 
the physicians to warn the people of the danger of these evils, bringing 
lasting disease upon themselves and a downfall to the nation. 

Our medical text-books and journals are advising the physicians 
to clean their ranks of all unprofessional practises, and begin their 
medical reform in their offices, ere it is too late. 

Realizing that it is the women and mothers with whom we have 
to deal, and through mothers we have to look for reformation for the 
welfare of our race, we therefore feel it the duty of women physicians 
to present this subject to the women. 

We are urged to contribute to •them our knowledge of practical 
experience, gleaned from women, as to the causes of so much ill health 
prevailing among them. We shall endeavor to instruct them from a 
medical standpoint and a common-sense view in a general way, using 
plain terms in plain English. We shall quote freely from various 
writers on the various subjects with which we have to deal, giving 
credit where credit is due. The pronoun "I" may be used when we 
feel that we need to do so. 

My soul's desire is that good may come from this small addition 
to our large amount of medical literature. Being a mother myself, 
and feeling as I do for the welfare of our dear mothers, I truly believe 
that the gospel truth contained in this book will be the means of sav- 
ing many lives, saving mothers from overwhelming sorrows, and 
bringing joy and sunshine to many a household. 

Knowledge of the causes of evils and errors prevailing among our 

(17) 



18 Introductory, 

children will be weapons in the hands of mothers "to put out the 
match before it becomes a conflagration. 7 ' Our young women should 
be instructed from a medical standpoint the responsibility of married 
life, and also the natural result expected as to raising children, an(j. the 
importance of letting nature take its course ; and the fruit of the womb 
should not be molested; that it is God's plan for the reproduction of 
the human species, who are born into this world to fulfil His law and 
carry out His purpose, and finally honor Him throughout all eternity. 

There is no doubt but that, in the first place, the medical frater- 
nity are responsible, in a great measure, for the depopulating of our 
Anglo-Saxon race, which is, according to statistics, fast becoming 
extinct. 

Women have been taught by their physicians some methods, con- 
sidered harmless, by which to prevent conception in some cases, which, 
in their judgment, should not conceive, not realizing how prone women 
are to communicate to their sisters or friends how their physician 
instructed them to regulate their family, or probably not bear children 
at all, if a family of children is not wanted. The physician does not 
realize when or where such teaching and advice will end; neither did 
they think, when such advice was first given, that it would ever be 
the foundation for so much ill health among our women. Since I 
have turned my attention to instructing the women upon this topic, 
many of them are seemingly surprised at the dangers resulting from 
such practises. Most of them look upon the matter as a harmless and 
a domestic economy. 

William Goodell, M. D., in referring to the prevention of concep- 
tion, says, "A deplorable practise which, like the plague of frogs, 
creeps into our houses and bedchambers and beds." It comes from 
the dilettantism of our women, which shrinks from having its 
patrician pleasures and esthetic taste disturbed by the cares of mater- 
nity. It comes from fashion, from cowardice, from indolent wealth, 
and shiftless poverty. It comes from too high a standard of living, 
which creates many artificial wants, and demands many expensive 
luxuries. I am amazed at the very low standard of morality with 
regard to the sexual relation obtaining in the community. So low, 
indeed, has it fallen, that I have known clergymen either themselves 
practising preventive measures or else abetting their wives in them, 
and physicians of repute teaching their patients how to avoid having 
offspring. To these detestable practises do I attribute, in a great 
measure, much of the ill health of our married women. "Why is it," 
asks a layman, J. Parton, "that in the regions of the United States, 
otherwise most highly favored, nearly every woman under forty is sick 
or sickly?" Why is it, I ask, that the waiting-rooms of our gynecol- 
ogists are crowded with so many querulous and complaining women, — 
women with groin-aches, backaches, headaches, and spine-aches; 
women either without sexual feeling, or else too weak to indulge in it ? 



Introductory. 19 

Why do so many women break down either shortly after marriage, or 
very soon after the birth of the first child ? — It is, I answer, because the 
majority of them, false to their moral and physical obligation, are 
trying either not to have children, or to limit their number. It is 
because, by an immutable law of nature, there appears to be no harm- 
less way by which the "seed of another life" can be made unfruitful. 
It is because the wife, sinning the most and most sinned against, suffers 
most. Be the mode of prevention what it may, so much engorgement 
and hyperplasia and disorganization of the uterine structures and 
appendages are apt to take place in the women who keep themselves 
sterile. Their health breaks down, and they are apt to lose all sexual 
desire. What physician is there of ripe years who has not been oppor- 
tuned by women hitherto wilfully barren, but now longing for children, 
to undo the mischief caused by such practises. There is another phase 
of this many-sided evil, — -an ethical one, — which, in a strictly medical 
work, may seem out of place, but health and happiness are so corre- 
lated that what harms the one hurts the other. Statistics show that 
divorces are multiplying in this land in a far greater ratio than the 
gain in population. In the New England states the increase is so 
alarming as to arouse the attention of patriots and philanthropists. 
Every year the divorces granted in these states break up over two thou- 
sand families. But these figures do not tell the whole tale of disrupted 
households, for they do not include the many cases of voluntary sepa- 
ration between husband and wife, or of an application for divorce in 
which the parties were denied by the courts. For instance, a few 
years ago Congress appropriated ten thousand dollars to bear the 
expense of an inquiry into the working of marriage and divorce laws 
in the United States. The official report was made to Congress on 
February 20, 1889. It shows that 328,716 divorces were granted in 
the twenty years between and including 1867 and 1886. A single 
state, Illinois, granted 36,072 divorces in that time. Ohio followed 
closely, with 26,367, and Indiana with 25,193. The total in all the 
states for the year 1886 was 25,535. In the year 1868 the number of 
divorces granted was 9,837. The increase, therefore, in twenty years 
was about 157 per cent. But in the same years the population only 
increased about 65 per cent, which shows that the evil of divorce is 
increasing more than twice as fast as our population. From statistics 
lately published by the clerk of Cuyahoga County, in which Cleveland 
is situated, it appears that during the past year 1,080 cases of divorce 
were put on record in the court, viz., one divorce to seven marriages.* 
Now why are there so many ill-mated marriages ? Why these 
unhappy homes and broken households? What means these separa- 
tions between man and wife ? I answer, They mean the violation of 
one of nature's immutable laws. Sex is a profound fact which under- 

* National Keform Document of 1890, 1894; New York Observer, October 26 1895- the 
Congregationalist, July 27, 1893. ' 



20 Introductory. 

lies all the relations of life and the fabric of society, and it can not be 
ignored. The love interchanged between man and woman is no mere 
operation of mind, no sheer intellectual process. However pnre this 
passion may be, it is necessarily an alloy, made up, like ourselves, of 
body and mind, the grosser mold so intermixed with the more ethereal 
that the one finds its most passionate expression in the fruition of the 
other. The sexual instinct is given to man for two reasons, — to per- 
petuate the species, and to rivet the tie between husband and wife, not 
only by offspring, but by mutual endearment. The conjugal relation 
is, therefore, twofold in its nature. It has a moral as well as a physical 
expression, the two so interwoven that it is impossible to dissociate the 
one from the other without doing moral as well as physical harm. 

The causes of domestic infelicity and ill-mated marriage are, 
then, to my mind, clear enough. The grossness of the carnal union 
is redeemed by its purpose, — the moral union, in which is involved the 
desire for offspring. Deprive the marriage tie of these qualities^ strip 
it of the family idea, and it loses its cohesiveness in intense person- 
ality and self-asserting individualism. When a wife soils the mar- 
riage bed with the artifices and equipments of the brothel, and quenches 
all passion by cold-blooded safeguards, and when she consults her 
almanac, etc., can she otherwise not expect estrangement or jealousy to 
be the result of such action 1 "Can a home with such environment be 
a happy one V 

The ill health and childlessness of our women are sources of 
national weakness, at which every patriot may well take alarm. 
Searching statistical inquiries show that the birth-rate of our native 
population is steadily and alarmingly decreasing. By the ill health 
of our women, and by their unwifelike behavior or preventive meas- 
ures, the American family is growing smaller and smaller, and the 
good old original Anglo-Saxon stock of our country, its brains, its bone, 
and its sinew, is rapidly dwindling towards extinction. For instance, 
from the records of six generations of families in some ~New England 
towns, the following facts were gleaned: It is found that the families 
composing the first generation had an average of between eight and ten 
children; the next generations averaged about seven to each family; 
the fifth generation, less than three for each family. The generation 
now coming on the stage is not doing so well as that. In Massachusetts 
the average family has numbered as low or less than three persons. 
Other states have not yet made such searching statistical inquiries, but 
there is no doubt that an alarming diminution in the Anglo-Saxon 
stock is taking place all over our country. In view of these facts, let 
us read two lessons from ancient history, and take warning from them. 

Time was when every prolific Roman matron received a civic 
reward. Then she would exhibit her children, as Cornelia did her 
twelve, and proudly say, "These are my jewels." Five hundred and 
twelve years elapsed from the foundation of Rome before the first 



Introductory. 21 

formal divorce was granted, and the divorcer till his death was pursued 
by the obloquy of his fellow-citizen. In those days nothing could with- 
stand the onset of the Roman legion. Rome ruled the known world, 
but Momsen tells us : "In the time of Julius Csesar, celibacy and child- 
lessness became more common; the family institution fell. The Latin 
stock in Italy underwent an alarming diminution." Divorces were 
now obtained on the flimsiest grounds. Criminal abortion was prac- 
tised on the slightest pretext; nay, indeed, it was lauded as a praise- 
worthy domestic economy. Marcus Aurelius foresaw the danger, and 
tried to avert the evil, but, being a pagan and a doctrinaire, he failed. 
So prevalent had the crime become in Juvenal's day, that he leveled 
one of his most bitter satires against it. In it he says that it was most 
commonly resorted to by the Roman ladies, lest pregnancy should mar 
their beauty or spoil their figure. They termed the unborn child the 
shameful burden, and got rid of it, lest its growth should disfigure their 
belly with scars. But national sins beget national woes, and the Roman 
Empire, overrun by northern hordes, perished for the want of men. 

Once the family institution was deemed the palladium of Hellas. 
The contemporary of Plato, of Socrates, and those heroes who fell at 
Thermopylae, prided himself on the number of his sons who could fight 
for his country, and boasted of the number of his daughters who could 
hold the distaff. 

Then Greece, for her superb heroism and magnificent pluck, won 
the admiration of the world. Her navies swept the Mediterranean, 
and her colonies studded the coasts. But (alas these "buts"!) one 
century and a half before the Christian era the serried ranks of the 
Macedonian phalanx quailed before the Roman legion, and the Greek 
became a vassal. Why this dire disaster ? — Because Greece, spoiled 
by prosperity and warped by vain philosophy, could not brook to have 
its classic tastes and esthetic culture interrupted by family cares and 
family ties. Polybius, her own countryman and historian, writes that 
"the downfall of Greece was not owing to war or to the plague, but 
mainly to a repugnance to marriage, and to a reluctance to rear large 
families, caused by an extravagantly high standard of living." 

Now what happened to Greece, what happened to Rome, may yet 
befall our own beloved country. It may die for lack of Anglo-Saxon 
men. The hour of need may come when, after great national calam- 
ities, after portentous reverses, the genius of this republic, disordered 
by an imperial grief, like that of the Roman emperor, may catch the 
burden of his cry, "Give me back, O Varus, give me back my legions !" 

The women would never have known how to regulate their fam- 
ilies to a few in number if the medical people could have had a "fore- 
sight" of any future evil resulting from such advice. The only hope 
now is that the physicians will see the error of their past experience, 
and advise their patients accordingly. 

Some women will say, "My husband does not want children." 



22 Introductory. 

We admit it is occasionally the case. However, it has been my observa- 
tion that the women are the most predominant in lessening the number 
of children. 

There is no doubt that the medical profession can be the means, 
in a great measure, through moral persuasion, of prevailing upon their 
patients to abandon all preventive measures, when they are made 
aware of the danger of bringing ill health upon themselves, and also 
can be the means of preventing broken households and many divorce 
cases, also preventing degeneracy of their children because of unnat- 
ural relations between husband and wife; and great good can be done 
in a few years toward building up the general health of our women 
through proper advice and moral persuasion by the physicians. 

The women are conscientious, and if they are advised as to the 
truthfulness of the injury resulting from these preventive measures by 
their family physician, many of them would heed the good advice 
given, and it would not be many years until the fashion of small fam- 
ilies would be reversed. All households are happier with children. 
What is a household without young people ? Children are the life and 
the spirit of the whole world. 

The preventive measure of reproduction soon renders the women 
barren. Many cases have come under my observation, and those who 
wanted a child had to undergo a course of medical treatment in order 
to become fruitful, and even then some of them failed. As age rolls 
on, they see the error of their ways; they yearn for children too late. 
They have sinned against nature ; they suffer self-reproach. 

In olden time it was considered the greatest earthly blessing to a 
household to raise a large family of children. A woman who was 
barren was looked upon with reproach. 

The Holy Bible tells us about the rejoicing of Rachel when she 
had a son for her husband, Jacob, after being barren for many years. 
Also Elizabeth, the wife of Zacharias, who was barren until stricken 
with old age, and when she found she had conceived, she rejoiced, and 
said, "Thus hath the Lord dealt with me in the day wherein He looked 
on me, to take away my reproach among men." 

At the present age, with some nationalities in this country, their 
wives are reproached for not bearing children. A Swedish woman 
came to see me a short time ago for medical advice, in reference to her 
being barren. She said her people reproached her for not bearing a 
child for her husband. 

Our Anglo-Saxon race, according to statistics, are fast becoming 
the barren race of the world. The burden of this national sin will lie 
on our American women. The woman will have to suffer the penalty of 
this depopulating of our country. 

There is childlessness in thousands of our American households 
which are blessed with an abundance of means to raise and educate 
children of their own or orphan children. They are childless through 



Introductory. 23 

their own selfishness, — too much fashion, too much indolence, too much 
desire to have a good time. With some, children are too expensive, 
too much trouble and care. 

The Holy Scripture teaches us, "I will, therefore, that young 
women marry, bear children, guide the house, give none occasion to 
the adversary to speak reproachfully." 1 Tim. 4 : 10. 

Why is the prevention of conception injurious to the health of 
women? — It is because the seed of the husband compensates the wife 
for that which he receives from her. In other words, the seed of the 
husband acts as a tonic for the vaginal walls of the wife. It is by this 
means God intended to propagate the human species. If anything is 
done to thwart that purpose, the woman suffers in consequence. The 
preventive measures have the same effect as masturbation upon the 
nervous system. 

From this unnatural relation between husband and wife, comes 
dangerous nervousness, sleeplessness, a creeping sensation up the spine, 
a dull, heavy sensation across the loins; it will cause headache (brain 
trouble, as I have heard it described, as if there were wheels in their 
head), extreme irritability, barrenness, and often insanity. 

The greatest hope is that all the physicians will perform relig- 
iously and zealously this medical missionary work in their offices, for 
the sake of humanity. Many a woman, when properly advised by her 
physician, will be profited by his or her advice. 

The awful sin of the present century, which is alarmingly fashion- 
able among our women, is criminal abortion, "infant murder." Any 
woman who commits a wilful abortion upon herself or has some one 
else produce an abortion upon her, is considered a murderess in the 
sight of God. 

Any physician who performs criminal abortion upon a woman 
when it is not legal to do so, that is, when the mother or would-be 
mother's life is not in danger, but for gain, or to please the patient 
because she does not want a child, is considered a murderer in the sight 
of God. If it is proven upon him, that he performed the act, he is 
sentenced to the state prison for the term of twenty years. 

I truly believe if our women were taught to know the reality of 
this crime, and the evils resulting from it, that many of them would 
not have the deed committed upon them. I believe their consciences 
would not permit them to have it done. 

There are few women, nay, if any, who are born without some con- 
science. They would seriously think a good deal before they could get 
up courage to go to their physician and deliberately ask him to destroy 
their unborn infants, flesh of their flesh, and blood of their blood. It 
is not natural for them to do so. There is, when they premeditate this 
act, something wrong in their minds. They do not realize the gravity 
of such an awful sin. 

Women have come into my office, in a cool, business-like manner, 



24 Introductory. 

and said : "Doctor, I am pregnant. I want you to do something for me 
to bring around my periods. I have just missed, and I thought it best 
to come soon, as I have heard if the courses were brought on early there 
is no harm in it, nor but little danger, if any. What is your opinion 
about it, doctor ?" My method is to let them get through talking before 
I interrupt them. They truly believed their friends, that if there is 
no life felt, it is no harm. I have succeeded in many, or most cases, 
through moral persuasion and warning, in teaching them, from the 
very depth of my soul, the terribleness of this crime. 

We are taught that from the very moment the male and female 
|eed approach each other, they clasp together, or embrace each other, 
and immediately a thin covering, as it were, a film or shield, is thrown 
around this new life, the beginning of the formation of a human being. 
It takes up its abode in its mother's womb, the home for it, until the 
Lord is ready to bring it forth into this life, to live, move, and have its 
being. 

The mother of this new life dwelling within her womb, the inno- 
cent of all innocence, deliberately destroys it, turns it out to die, even 
though she risks her own life in doing so. This is, in the sight of God, 
and according to the laws of our land, committing a terrible crime, and 
it can not be denied. A very few women, perhaps, may scoff at the 
idea of its being a sin, and it appears that they do persuade themselves 
it is no sin. 

I have heard women argue, that in the early stages of pregnancy 
it was no sin, but that later on it might be a sin. Notwithstanding, if 
the physician is found guilty of this act, in early pregnancy, — if it is 
proven against him, — he is sent to the state prison just the same. ~No 
physician would ever be guilty of this infant murder if the women 
could be prevailed upon to let nature take its course. 

It would be well for mothers to instruct their daughters before 
they marry, the consequences that they may expect to follow a marriage 
ceremony. If they are willing to bear children, get married; and if 
they are not willing to let nature take its course, it would be much wiser 
and better to remain single. 

Those who do marry should put their trust in God, bear children, 
guide the house, serving the Lord, and the world will be better off for 
their having been born into it, and, according to Scripture teaching, 
their crown will be everlasting glory in God's holy city. 

The causes of ill health in our children are many. In children 
we have the hereditary diseases, such as consumption, cancer, leprosy, 
gout, rheumatism, syphilis, epilepsy, paralysis, alcoholic tendencies, 
and insanity. 

We have the enteric diseases, due to parasites, as worms, malarial 
diseases, typhoid fever, yellow fever, bubonic plague, cholera, cholera 
morbus, diarrhea, and dysentery. 



Introductory. 25 

We have the zymotic diseases, as the measles, scarlet fever, 
scarlatina, variola, whooping-cough, and the mumps. 

We have croup and diphtheria. 

In young infants we have hives and thrush. 

We have various skin diseases, eczemas, etc. 

We have nervous diseases, as St. Vitus' dance. 

We have various diseases due to bad hygiene, bad drinking water, 
poor ventilation, improperly-cooked food, and poor food. 

We have diseases due to cold, as pneumonia, erysipelas, bronchitis, 
catarrh, and la grippe. 

Bad habits are formed in children in early life, or as early as 
eighteen months of age, for the lack of proper care from the mother 
or nurse, not knowing anything about how bad habits are formed in 
little children. They will acquire the habit of scratching the genitals, 
due to an irritation of the parts by uncleanliness, chafing of the parts 
from irritable urine, from pinworms or seat- worms, from too warm 
clothing, from stiff starched drawers, the seam of which will chafe little 
girls, and which should be loose, and never fit very close to the child. 

Any or all of these will cause an irritation between the labia of 
little girls, and nature tries to heal the parts, and can not, because the 
irritation is kept up, causing an itching of the genitals. Hence, from 
the habit of scratching, is liable to be formed the habit of masturbation, 
which the writer has observed. Whereas, if mothers have the knowl- 
edge of these facts, and causes of such habits being formed in little 
girls, they can soon check the habit, by keeping the genitals clean, etc. 
Put one level teaspoonful of boracic acid into a half teacup of water ; 
agitate it until dissolved. Wash between the labia with castile soap 
and warm water, dry the parts, and mop the boracic solution on for 
four or five minutes, then dry the parts, and put on oxide of zinc oint- 
ment made with pure vaseline, one and a half drams oxide of zinc to one 
ounce of vaseline. The little girl should be taught that she must tell 
her mother or nurse when she itches about these parts. 

Little boys, very early in life, will form the habit of pulling the 
penis, which should not be allowed. I have known of cases of little 
boys masturbating, due to phymosis, a stricture of the prepuce, or fore- 
skin, which causes a smegma-like substance to form behind the stricture, 
setting up an irritation of the organ, causing an itching, and the 
habit of scratching for present relief will, in all probability, lead the 
boy to form the habit of masturbation. The boy must be circumcised 
as the only true method of cure. Worms and irritable urine are 
responsible for the habit of masturbation in both sexes. Bad associates 
are alleged to be the cause sometimes. 

The irritation above mentioned has, in my observation, been the 
cause of masturbation in every case brought to me for treatment, 
whether boy or girl. 

The writer firmly believes the habit can, in a great measure, be 



26 Introductory. 

checked almost entirely if mothers and nurses can have the knowledge 
of the causes of bad habits being formed in early life. The rule 
should be, cleanliness all the time, especially cleansing the children 
before putting them to bed. The children should be taught from baby- 
hood that they must be washed every day to keep well and healthy. If 
the habit of cleanliness is taught to children in early life, very few of 
them will depart from it in manhood or womanhood. 

Every male child born should be examined at birth, to see whether 
it is perfectly formed. The foreskin should be especially exam- 
ined. If prepuce, or foreskin, can be made to push back partly over 
^the corpus cavernosum or partly over the head of the penis, just so that 
the meatus or opening of the mouth of the urethral neck of the bladder 
can be observed, the boy is all right. But if the prepuce, or foreskin, 
can not be pushed back so as to see the mouth of the neck of the urethra, 
and if the foreskin has the appearance of a drawstring around the end 
of it, the child has a stricture of the foreskin. An operation is highly 
essential. Circumcision should be performed early, after ten days or 
two weeks of life. The Jewish plan is good. Dilation of the fore- 
skin is not a good method. The stricture returns. 

If there are any animal parasites, pinworms, etc., they should be 
treated for worms. If there is irritation from urine, causing an inflam- 
mation of the urethra and prepuce, it should be treated by your 
physician, or by a specialist. If the irritation should be due to any 
rectal troubles, causing irritable nervous trouble, complicating the 
inflammation of the urethra in girls, or foreskin in boys, and no stricture 
present in the boy's case, the best medical skill should be employed to 
take charge of the child's case. 

Every mother should have her boys examined, under the age of 
manhood, and if such trouble as stricture exists, have it attended to at 
once. Quite a number have come under my observation since I have 
commenced this missionary work. If boys thus afflicted are circum- 
cised, this will prevent future weaknesses from arising, and bad habits 
will not be formed. 

The Cause of Hysterics in Children. — The most predisposing 
causes may be ranked heredity, improper educational methods, neglect 
of physical health, the ill effect of bad examples, unusual hardship, 
climate, and depraved condition of the blood. 

Grasset, Briquet, Amann, and others give statistics to show the 
more or less direct transmission of the disease from parent to children, 
especially from mother to daughters. In such cases both the inherit- 
ance and the influence of parental examples may assist in producing the 
disorder. The inheritance of hysteria, as of other nervous diseases, is 
not often direct. The neurotic constitution is the most frequent 
predisposing cause. 

The tubercular diathesis, or consumptive tendencies, and catarrhal 
tendencies in children, also syphilis, chorea or St. Vitus' dance, poor or 



Introductory. 27 

badlj cooked food, imperfect ventilation, too little sunshine, overheating, 
exposure, want of cleanliness, bad hygienic surroundings, will lead to 
developing of hysteria and other nervous affections in many children. 
Habitation often has a marked tendency to the development of hysteria. 
Chilly, sunless apartments, which are poorly ventilated, sap nervous 
vitality from little children. Children should live in sunny rooms, 
with southern exposure. They should be given the preference of the 
best sunny apartments. 

Bad educational methods may act as a predisposing and exciting 
cause in children. About examination times in schools, hysteria is 
often manifested. Social conditions are occasionally active in the 
development of hysteria. In our large cities many houses are so poorly 
supplied with grounds, yards, or courts for out-of-door exercises for 
children, that hysteria is developed in consequence. 

Parents should supply their children with indoor amusements, as 
games, etc., and take an interest in their amusements. Only by proper 
indoor and outdoor life can nervous breakdowns be avoided. 

Many observations have been made by Mitchell and Lewis and 
others, on the effect of climate and seasons, on chorea in children, who 
are often hysterical in nature. 

Various disturbances of the sexual organs are predisposing and 
exciting causes. Also masturbation is, undoubtedly, a very common 
cause, in both boys and girls. On the weak and sensitive children it 
produces various forms of nervous breakdown. 

Hysterical symptoms sometimes develop in children, apparently 
from the result of their being in the company of their seniors. 

The lack of moral training received by the children of hysterical 
mothers is a cause of hysteria. Ill treatment, moral or physical, also 
fear or fright, or false accusations, will cause hysterical attacks. 

Injuries in children and adults will cause a great variety of hys- 
terical manifestations. I have known of young girls immersing them- 
selves in cold water at the time of puberty, also during their monthlies, 
causing the most intense hysterics, through fear that they would not 
recover. 

Fright will cause a sudden stopping of the menses, causing 
hysteria ; also grief and regret will cause hysteria. 

The physical phenomena are not so intense or persistent or multi- 
plex as in older patients ; and, therefore, a true, continuous, hysterical 
insanity, lasting for weeks or months, is not likely to be observed in 
early years. 

Many children are born into the world not wanted. Through the 
mental or maternal impressions of the mother, or father upon the 
mother, not wanting a child, and through their lamentations and mental 
worry over the unborn child, they are likely to affect the child during 
its development. The child will, in all probability, simulate the actions 
of its mother or father as it develops into manhood or womanhood, 



28 Introductory. 

taking on its parents' actions, whatever they were, during the time ifc 
was developing or during the term of gestation. It is thought that 
through mental impressions the child may be impressed, or moulded, 
for better or for worse, according to the mental condition of the mother 
during that period of time. 

When a woman is aware that she has conceived, or is pregnant, 
from that very moment she should commence to mould the character 
of her unborn child. She should take the greatest care of her health, 
both mentally and physically. Her thoughts should be of the purest 
character. She should cultivate the best principles; cultivate cheer- 
fulness, and happiness, and kindness to all people; above all, cul- 
tivate charity, and patience, and faith in God; think of noble deeds, 
and cultivate honor, integrity, and justness to all people. It is neces- 
sary that the husband should take part in aiding his wife, through men- 
tal culture, for the good of the coming offspring. You want good blood, 
bone, and sinew in your child. Hence, you should eat good, nutritious 
food. Eat nitrogenous food, as eggs, meat once a day, drink milk, eat 
fruits and vegetables. Do not eat very much starchy food, such as 
bread or rice or cereals of any kind, after the seventh month of preg- 
nancy; also, eat sparingly of pie, and cake, and candies. You do not 
want to lay up an over-accumulation of fat. 

Take plenty of exercise, short of fatigue; keep the bowels open, 
and the mind occupied. To be idle is not' good for the offspring or 
the mother. 

The mother's hand that "rocks the cradle" bears the burden of the 
human race. Through the mothers the world is to be made better; 
through mothers' influence over their sons and daughters, from the time 
they are conceived until they are born, and through the influence and 
teaching of good mothers and Christian mothers, the sins of the world, 
the crimes of every kind, can be made to fade away, if all mothers and 
would-be mothers can be scientifically enlightened in the knowledge of 
the good influence that can be rooted in the child through good mater- 
nal impressions. IsTo doubt many children are influenced for good or 
bad according to the mental impressions and surroundings. 

If the mothers will look upwards to God Almighty for wisdom, for 
knowledge, and faith, as to how to care for their unborn children, He 
will bless them accordingly. The Holy Bible teaches that God forsakes 
not the woman in travail, if she puts her trust in Him. 

There is no doubt that the mother can improve the condition of 
her offspring by keeping her mind and body in a healthy, active con- 
dition, moulding the character of her unborn child, that it may be 
brought to nearer perfection of humanity ; that when born it will have 
a perfect body and mind. 

The human species can be brought to such perfect development 
through the influence of mothers, that the coming generation can live 
a life of unselfishness, and self-sacrifice, and Christian love towards 
each other, and fulfil the ten commandments. 



CHAPTER II. 

GENEKAL DISEASES OF WOMEN" AND CLINICAL HIS- 

TOKY OE CASES. 

I will briefly mention the more common kinds of diseases, and of 
pain complained of, and the character, as far as they have any. 

Most women, when questioned as to the character of pain of which 
they are conscious, will describe it as a dull, heavy ache. This is 
especially true of backache, which is the most common form we meet 
with ; also of pain low down over the pubes, and across the lower 
abdomen. This is also the kind of pain felt in the groins and thighs 
and hips. Such pain, whether constant or only present on exercise or 
after fatigue, suggests some chronic trouble, — congestion, displacement, 
laceration, or remote results of acute inflammation. Chronic aches 
will vary in character. Pain in the back, confined to a small area at 
about the junction of the lumbar and sacral vertebra, and of a more 
burning character, is suggestive of some trouble with the cervex-uteri, 
such as endocervitis, more often laceration. A bearing-down pain, or 
a feeling of weight and pressure, as it is described, when less pro- 
nounced, is caused by a lack of harmony between the uterus and its 
supports, and an increase in weight of the one or a loss in strength of 
the other. Sharp pain is usually symptomatic of some acute condition, 
either inflammatory or of neuralgic origin, or due to spasmodic contrac- 
tion of muscular fibers. If pain is in the abdomen and associated with 
fever, it suggests localized or general peritonitis ; if without fever, 
either neuralgia or a peculiar hyperesthetic affection of the abdominal 
walls, that simulates peritonitis. If coincident with the menstrual flow, 
it has a special name, — dysmenorrhea, — which, however, throws no 
light on its causation. The seat of pain is a symptom of value. When 
situated in the lower abdomen — a very common complaint — if in the 
median line, just above the pubis, it usually indicates some uterine 
trouble; if at the sides, just above Poupart's ligament, or what is 
called ovarian region, it suggests trouble with the appendages, or it may 
be ovarian, or disease of the tubes, and is most likely to have its seat 
in the peritoneum, which invests the pelvic organs. Pains in the back 
have been mentioned. Pain in the hips and thighs, extending as far as 
the knees, is usually a symptom of pressure in the pelvis. 

Disorders of menstruation relate to abnormalities of the menstrual 
function. These are amenorrhea, oligomenorrhea, monorrhagia, and 
dysmenorrhea. 

(29) 



30 General Diseases of Women. 

AMENORRHEA. 

This is a very common complaint. In the primitive form, it 
has to do with young women in whom this function has not appeared, 
and who are either suffering in some way, to suggest that 
its non-appearance may be the cause, or, while free from suffering, 
have so far passed the age at which it usually appears as to excite sus- 
picion that there may be some trouble. A thorough examination 
(physical) is necessary, whether there is any, or have been any abdom- 
inal pains occurring monthly or not. If there is suffering, especially 
*of a periodical character, a simple examination to determine the pres- 
ence or absence of any abnormality, such as absence of the uterus, or 
atresia of the vagina, should be made. 

Acquired amenorrhea has a variety of obvious causes, which must 
be carefully considered, and which the patient's history may throw 
some light upon. The most frequent of these is pregnancy, and it is 
often for the patient's supposed interest to conceal this condition, though 
it should not be overlooked. Atrophy of the uterus following child- 
birth, change of climate, especially when accompanied by a sea voyage, 
and obesity, are other frequent causes of amenorrhea. 

OLIGOMENORRHEA. 

This is said to depend upon general conditions much more than 
upon local. 

MENORRHAGIA. 

Menorrhagia varies in importance as a symptom with the time 
of life at which it occurs. It is not at all uncommon in young 
women or girls, and is then usually an expression of some gen- 
eral condition incident to adolescence. It may be caused by anemia, 
which is in turn the result of over-stimulation of the brain, lack of exer- 
cise, and neglect of the proper hygienic conditions ; or it may occur in 
apparently healthy girls, presumably a symptom of local congestion. 
Usually rest, general tonic, and hygienic measures suffice for its relief. 

In middle life, especially after marriage and child-bearing, and 
other causes, menorrhea develops. Prominent among these are endo- 
metritis, fibromyomata, and polypi of the uterus, and general debility. 
The cause is decided by an examination. The menorrhagia may be 
due to endometritis. If so, it is more apt to show itself by a prolonged 
menstruation, and that due to fibroids or polypi, by a profuse flow more 
hemorrhagic in character. 

Menorrhagia occurring at, or about the time of the menopause, 
while possibly dependent upon that change, and a symptom of it, is yet 
so suspicious of either a fibroid or malignant disease, that a vaginal 
examination should never be neglected. 



General Diseases of Women. 31 



METRORRHAGIA. 



This form is dependent, very much, upon the same conditions; 
it is hemorrhage from the uterus, occurring between the menstrual 
periods. This is so unnatural, or abnormal, that it should be thor- 
oughly investigated. It should never be neglected. Endometritis and 
fibroids may give rise to this symptom, in their later stages. There 
may be added other causes, as pregnancy and its complications, and 
malignant growths. Pregnancy and malignant growth are apt to be 
accompanied by metorrhagia from the beginning, while the former 
usually begins with menorrhagia. The presence of tumor, and the 
usual sign of pregnancy, and the occurrence of pain, and foul discharge, 
is significant of one or the other, and a physical examination must be 
made to settle the question. 



DYSMENORRHEA. 



This is another abnormality of menstruation. It is painful 
menstruation. If the pain comes on a day or two before the 
appearance of the flow, it is due to some general disturbance of the 
circulation of the pelvic organs, or nerve supply, especially in the 
ovaries or uterus, and is usually characterized as neuralgia or congestive 
dysmenorrhea. If it comes on with the flow, it lasts for a day or two, 
and then ceases. It is usually due to some condition of the canal of the 
uterus, from the flexed cervix or long body of the uterus, or from 
cicitricial tissues filling up the uterine canal, etc., and is named 
obstructed dysmenorrhea. Where the flow is painless at its onset, but 
becomes more profuse, and shows a tendency to clot, the efforts of the 
uterus to expel the clot will be accompanied by severe, cramp-like pains. 
This may be called the spasmodic form. 

Nearly all kinds are accompanied by pain in the back and in the 
lower part of the abdomen, and a bearing-down sensation, the congestion 
being mostly of this character, though, as a rule, milder. In the 
obstructed form the pain is usually very much more severe, more con- 
centrated in the uterus, and accompanied by reflex symptoms, as nausea, 
headache, and often vomiting. The patient is sometimes thrown into 
a state of convulsions. This severe form of painful menstruation comes 
most usually from anteflexion or retroflexion of the body of the womb, 
or both. 

The next most common cause of painful menses is an extremely 
sensitive condition of the os, and is sometimes accompanied by endo- 
cervitis, sometimes not. 

EEUCORRHEA. 

Under this head all discharges which are from the vagina will 
be included, except blood. 

Vaginal leucorrhea is thin, creamy, non-viscid, and, as a rule, not 
very profuse. If it is due to acute vaginitis, it is accompanied by 



32 General Diseases of Women. 

heat and swelling of the vulva and vagina, and, when gonorrheal in 
origin, not unfrequently by urethritis. When chronic, the heat and 
redness disappear, and the thin, creamy discharge sometimes changes 
to a thick smegma-like secretion, which clings to the wall of the vagina. 

Cervical leucorrhea is clear, like the white of an egg, viscid, and 
non-irritating. A thick, opaque, or yellowish discharge makes its 
appearance in clumps, at intervals, often only when some straining 
occurs, as during micturition or passing the feces, or on coughing or 
lifting. It is characteristic of endocervical catarrh. When the inside 
of the uterus (endometrium) is affected, the discharge is usually 
thinner than where it is purely cervical (in the neck of the uterus). It 
is, very apt to be of a brownish color, due to some admixture with blood, 
and may have a slight odor. When the secretions from the uterus are 
considerably purulent, it suggests tubal disease. 

A watery discharge is usually associated with only one of four 
conditions : pregnancy, with escape of liquor amnii, or hydatif orm mole, 
fibroid tumor of the uterus, or hydrosalpinx, with the periodical escape 
of the contents of the tube. With the history of the case and physical 
examination, the differential diagnosis is made. 

A foul-smelling discharge may arise from the retention of the 
normal secretions. This may occur as a result of atresia, following an 
operation. More frequently it denotes either the decomposition of 
material, as the retained products of conception, or the breaking down 
of abnormal growths, such as fibroids or malignant disease. 

ENLARGEMENTS. 

A patient very often becomes conscious of any enlargements 
of the external genitals. If acute, and accompanied by pain, it 
is most often a swelling of the vulvo-vaginal gland, either a cyst 
or an abscess, and occupies the lower part of the labium majus of 
the affected side. The other swellings of the external genitals may be 
hematoma of the vulva, to which the history will point, hernia, chronic 
hypertrophy of one or both of the labia major a, due to syphilis, and 
primary epithelioma of the clitoris or vulva. Swellings of the vagina 
are due to a prolapsed uterus presenting at the vulva, or prolapsed 
anterior or posterior vaginal walls, or a foreign growth, such as fibroid 
polypus, which has become extruded from the uterus into the vagina, or 
rarely an extensive epithelioma of the cervix, which has filled up the 
vagina, and can be seen protruding through the vulva. 

Moderate enlargements of the uterus are not recognized by patients 
as such. The symptoms of enlargements of the womb are an increased 
feeling of weight in the pelvis, backache, pain in the thighs, with 
inablity or interference with locomotion, increased amount of leucor- 
rhea, and frequent micturition. These are the local symptoms. 

The reflex symptoms to which uterine enlargements give rise are 
quite common, and as important. There are nausea and vomiting, 



General Diseases of Women, 33 

headache, sensitiveness, swelling of the breasts, flatulence, constipation, 
and general nervous disturbances. These are often the only symptoms. 
The local manifestation being absent, the most common cause of enlarge- 
ment of the uterus is pregnancy, sub-involution, and chronic metritis, 
fibroids, and malignant disease. The history will enable one to decide 
between these. 

ABDOMINAL ENLARGEMENTS. 

A woman is often unconscious of the existence of a consid- 
erable swelling in the abdomen, especially if unaccompanied with 
pain. Sometimes there is increased pressure in the pelvis, on 
account of bladder and bowel symptoms, frequent or difficult mic- 
turition (urinating), and constipation. Sometimes nausea is asso- 
ciated with other enlargements of the uterus, as well as from preg- 
nancy. Shortness of breath on exertion, palpitation of the heart, sense 
of fulness after taking food in small quantities, flatulence, swelling of 
the feet and ankles, and pain in the legs, are hints of abdominal pressure. 
The patient is often conscious of a weight shifting from one side to the 
other on turning, or of an inability to lie on one side or the other, on 
account of discomfort in the lower abdomen. If the enlargement is 
due to ascites, it will be flattened at the top, symmetrical, bulging at 
the sides. If it is due to pregnancy or an ovarian tumor, it will be 
prominent in the middle, falling off rapidly at the side. If it is due 
to a fibroid, there will usually be irregularities of the outline. A 
physical examination by a specialist will soon decide the true conditions. 

Disturbances of Function. — Those of menstruation have already 
been discussed. Others remain to be mentioned, viz., coitus, defecation, 
and micturition. Painful coitus is called dyspareunia. The most 
common cause of this is such extreme sensitiveness of the iiitroitus 
vaginas that intercourse may be impossible. This is characterized 
as vaginismus, and has various causes. Attempts at sexual inter- 
course may be painful where there is no vaginismus present. A 
very rigid, thick hymen may present an insuperable obstacle to inter- 
course, also an abnormally small vulva and vagina may be a cause. 
Congenital malformations, such as atresia of the hymen or vagina, must 
also be considered. In the absence of these conditions, coitus may be 
possible ; but it is accompanied with pain, which is then usually due to 
abnormal sensitiveness of the uterus, its appendages, or surrounding 
tissues. A vaginal exploration only will determine the question. 
There are also cases where coitus is followed by general nervous 
phenomena, i. e., cramps, fainting, headache, palpitation of the heart, 
and nausea. 



34 General Diseases of Women. 

DEFECATION. 

Disturbances of the function of defecation are very common. 
Constipation may be said to be almost the rule with women, and 
a more precise knowledge of its various forms will be of material aid 
in judging its cause and applying appropriate measures for its relief. 

The term itself is of varying significance among women. Some 
understand by it a difficult movement, even though it occurs every day, 
and at a regular time. Another woman would not call herself consti- 
pated, even though she did not have an evacuation for two or three days, 
^provided that it occurred then without the use of medicine. Still 
another considers that her bowels act naturally, even though she is 
obliged to use some artificial means every day, provided such means are 
effectual. 

There is one form which depends on a sluggish condition of the 
bowels, due, perhaps, to a loss of muscular power in the walls of the 
intestines, or to inefficient innervation. In this form the bowels fail 
to propel their contents along, and the rectum remains empty. There 
is, therefore, no desire to have a movement. There is another form 
where the trouble seems to lie in the upper part of the rectum. Feces 
accumulate in the descending colon and the sigmoid flexure, but fail to 
enter the rectum. The cause is usually due to some pressure within the 
pelvis or the rectum, due to a displacement of the uterus, or to some 
enlargement either of the uterus or its appendages, or to adhesions, and 
consequent immobility of any of the pelvic organs. There is still a 
third form of constipation, where the bowels do their work properly, 
and the feces are satisfactorily carried along to the rectum; but the 
expulsion power seems to be at fault. The patient can not use force 
enough to expel the contents of the rectum, unless they are very loose. 
The most common cause of this is a weakening of the muscular struc- 
tures which constitute the floor of the pelvis by laceration during 
parturition. Or, if the perineum is not torn, and the muscular 
attachments even only stretched, this loss of power may result. 

The least special form of constipation is that associated with affec- 
tion of the anus, such as hemorrhoids, fissures, or fistula, where the pain 
is, that is sure to be occasioned by the act of defecation preventing the 
proper relaxation of the sphincter. Painful defecation is most often due 
to troubles of the anus, as above mentioned. Not infrequently it causes 
pain higher up: first, generally in the lower abdomen; and second, in 
certain organs, such as the womb or one of the ovaries, most often the 
left. The cause of this pain is sometimes obscure; in other cases it 
seems to be occasioned by the pressure of the feces upon a displaced 
and sensitive ovary, or a swollen tube, or even upon the body of the retro- 
displaced womb. Sometimes the mere act of straining is followed by 
discomfort throughout the pelvis, which in some cases may persist for 
hours. 



General Diseases of Women. 35 

To determine which one of the various forms of constipation is 
present, a thorough examination of the pelvic organs should be made by 
the vagina, and rectum, if necessary. 

The disturbances of the function of micturition which are notice- 
able are the frequency of the act and pain accompanying it. Some- 
times frequent urination seems to be a habit, and is expressive of the 
nervous temperament of the patient. One of the most common causes 
is pressure of the displaced womb on the bladder ; perhaps the uterus is 
enlarged, or there is some growth or swelling which prevents the proper 
distention of the bladder. Irritation or inflammation of the urethra, 
especially if it has extended to the neck of the bladder, is an exceedingly 
common cause, and cystitis, of course, is always accompanied by this 
disturbance of function. Alteration in the character of the urine will 
cause a frequency of the act. 

Pain accompanying the act of micturition may, for the purpose of 
diagnosis, be considered as occurring before or after the act. . If the 
pain is before the urine passes, it is usually symptomatic of some affec- 
tion of the bladder itself, which may extend from the bladder side, so 
as to involve the neck, in which case the very beginning, as marked by 
the relaxation of the sphincter, is painful. If the pain is a little later 
in the time of occurrence, giving the sensation of an intense burning 
at the vesicle neck and running down the urethra, it suggests fissure or 
ulceration of the neck of the bladder, with or without urethritis. If 
the pain is felt only as the urine passes from the urethra, there is some 
cause at its mouth, and it should be looked for. It may be carbuncle, 
ulcerative process, polypi, or a prolapse of the mucous membrane. Irri- 
tation about the vulva may cause pain during or after micturition, from 
the urine trickling over the sensitive surface. The closure of the 
sphincter vesica? at the end of the act may give rise to severe, cramp- 
like pain, just as its relaxation at the beginning. Examination of the 
urine should be made. 

Reflex Symptoms. — They are the reflex symptoms, or those which 
affect other organs than those which are primarily the seat of the trouble. 

It may truly be said that there is scarcely an organ of the body 
which may not be, and is not sometimes, functionally disordered as a 
result of disease of the pelvic organs. Even the eye and the ear are not 
exempt from this law. Sometimes these symptoms are wholly a result 
of the preexisting pelvic condition; sometimes they have been present 
before, and are only aggravated by it. One of the most obvious exam- 
ples of a reflex symptom directly dependent upon the pelvic condition is 
the nausea of pregnancy. But the greater part of such phenomena are 
much more obscure. We will only point out a few of the more common 
reflex symptoms, which we meet with in the course of our every-day 
experience. 

^ The digestive system is, perhaps, the most easily affected. The 
patients complain most often of the various aberrations of function to 



36 General Diseases of Women. 

which the stomach and bowels are subject. The nausea of pregnancy 
we have mentioned. But this symptom may be associated with other 
pelvic troubles. This is especially true of those conditions which are 
characterized by an increased size of the uterus, such as myomata or 
chronic metritis. Diseases of the ovary may be accompanied by nausea, 
and the nausea of dysmenorrhea illustrates again the close connection 
between the uterus and the stomach. 

Other disturbances of function are very common. The various 
forms of dyspepsia, flatulency and constipation or diarrhea, need only 
to be mentioned to be recognized as the most frequent accompaniment 
of uterine disease. 

The circulatory system has its share of reflex symptoms, which 
express themselves in palpitation, dizziness, fainting, and tingling or 
numbness, especially in the extremities; also flushing, incident to the 
menopause, and other irregularities of the circulation. 

The manifestations on the part of the nervous system are manifold. 
Neuralgia in various parts of the body, headaches of various forms, 
cramps and paresis and sleeplessness, indicate but in a general way some 
of the forms in which pelvic disease may show itself in remote portions 
of the body. 

Irritability, loss of self-control, from its incipient stages up to well- 
marked hysteria, inability to concentrate the attention, forgetfulness, 
and confusion of thought, are a few of the most evident manifestations. 

The foregoing brief sketch of the general forms of reflex symptoms 
merely enumerate what may occur. The important point to decide in 
the given case is how far such symptoms are the cause of, or dependent 
upon, the so-called diseases of women. This is often very difficult, 
especially when the local symptoms are either absent or so overshadowed 
by the general and remote symptoms as to be overlooked. The innate 
skill of the practitioner, and a wide experience, show their real value 
here. 

Francis H. Davenport, M. D., says, " Where pelvic symptoms have 
preceded the reflex manifestations, even though the former may have 
nearly or wholly disappeared, it is safe to suspect the local trouble as 
the cause." This is more apt to be the case if the first trouble followed 
some acute affections of the pelvic organs, as gonorrhea, a miscarriage, 
an attack of pelvic peritonitis, or a difficult or abnormal labor. Again, 
if the reflex symptoms are aggravated at the time of menstruation out 
of proportion to the normal effect upon the nervous system, it is suffi- 
cient to warrant the supposition that the uterus or its appendages may 
be at fault. An examination should be made to clear up the diagnosis. 



CHAPTEK III. 
INFLAMMATIONS OF THE FEMALE GENITAL OKGANS. 

INFLAMMATION OF THE VULVA. 

The causes of the inflammation of the vulva (vulvitis) are due, 
as I have often found in young girls, to a severe cold settling in the 
pelvic organs, causing an acrid catarrhal discharge, and the lack 
of hygienic attention of those parts, due to lack of knowledge on 
the part of the patient; and modesty prevents her from mentioning 
her condition to her seniors until her condition becomes unbearable, 
and she seeks the advice of her physician; gonorrheal and septic 
inflammation such as belongs to or springs from cancerous ulcer- 
ation of the cervix; the contact of irritable urine, and especially 
alkalinity of the urine, and in aggravated cases of cystitis, and the 
urine of diabetic patients. The author has now a patient, aged four- 
teen years, who has diabetes, and whose vulva is constantly becoming 
inflamed from the effect of the diabetic urine. Inflammation of the 
vulva is often caused by masturbation. 

Acid urine in children will often produce an inflamed condition 
of the vulva. The urine should be examined to find the cause, and 
have it removed, ere it is too late. Many children form the habit of 
masturbation from rubbing or scratching the vulva to relieve the itch- 
ing that the excoriating urine produces. Mothers should pay strict 
attention to the hygienic condition of the genital parts of their chil- 
dren. The vulva should be washed with pure castile soap and warm 
water, then rinsed carefully, and oxide of zinc ointment applied, 
keeping the parts clean. 

In married women (also, sometimes, unmarried ones, too, for that 
matter) inflammation of the vulva is due to too frequent coition, and 
want of cleanliness. An excess of exercise in fat women will likewise 
cause it. The strumous diathesis, or an invasion of oxyuride from 
the rectum will cause it, in both young and old women. Only a few 
days ago I had to prescribe for an elderly woman, who was troubled 
with an extreme itching of the anus and vulva, due to oxyurides. 
I prescribed pumpkin-seed tea, followed with a dose of castor oil. ( See 
chapter on worms.) After the bowels were thoroughly moved, and the 
rectum washed out, an infusion of quassia chips was prescribed to be 
injected into the rectum, while reclining, and the infusion retained. 
Following this, sulphur ointment should be applied with a syringe (a 
salve injector). This treatment is to be repeated every nine days, for 
three different times, until all the larvae are removed. 

(37) 



38 Inflammations of the Female Genital Organs. 

The exanthemata will cause it, but merely as a part of the general 
implication of the tegumentary tissues and mucous structures. 

Pathology of Acute Inflammation of the Vulva. — The surface pre- 
sents the usual appearance of active inflammation, the lesion being most 
pronounced about the vestibule and the ostium vaginse. Later the 
mucous glands may be obstructed, leading to a form of acne. The 
sebaceous glands on the outer side of the labia major a may also be 
involved, and complication of the vulvo-vaginal glands, one or both ; they 
may become so inflamed as to suppurate, untimately, and discharge as 
abscesses, or, through stoppage of the duct, may be converted into cysts. 
Gonorrhea is said to be the most common form of this lesion. The per- 
sistence of any one of the causes will develop a chronic inflammation, 
which, in cases dependent upon urinary irritants, especially, will lead 
to a thickening, hardening, and Assuring of the inner labial surface. 
After gonorrhea, condylomata may develop about the vaginal orifice. 

The most striking symptoms are those associated with gonor- 
rhea, which we will leave to be mentioned in connection with vaginitis. 
Those inflamed conditions dependent upon exanthemata, or upon dis- 
charges from septic metritis, are lost sight of by the patient in the 
general discomfort. The acute symptoms are a sense of fulness in the 
parts, pain in the region, when walking or when touched, and conscious- 
ness of a discharge. 

In the sub-acute and chronic forms, fulness and soreness in the 
region, especially after motion, are present. There may be excessive 
discharge, and, after urinating, there will be smarting. Soon after, 
pruritus appears, this being a prominent symptom in diabetes. 

When the vulvo-vaginal gland is attacked, the patient usually 
presents a distressing look, the recumbent position, with legs apart, being 
the only easy one. Sitting and walking are both very painful. As the 
inflammation progresses, distending the tissues, the symptoms of a sur- 
face plegmon are developed, with more or less constitutional reaction. 
The gland involved is seen distended to the lower half of the labia 
major a, and is extremely sensitive to the touch. The orifice of the 
gland, not easily seen as a rule, is now red and pouting, and pus may 
be pressed from it. After a few days it may point and discharge upon 
the inner face of the labia, or it may empty itself along the duct, and 
subside or degenerate into a cyst at a later period. If it is of a 
gonorrheal origin, it will probably light up at some subsequent period. 

The Treatment. — "Removal of the cause is the key-note." This 
may be impossible. If the gonorrhea was transmitted from the hus- 
band to the wife, the husband should be treated as well as the wife. 
The first step is to give an antiseptic vaginal wash, and thoroughly 
apply the lotion to the vulva. Cupri-sulphas from gr. ss to gr. j to 
one ounce of warm water. After having taken a hot vaginal douche, 
and after using the antiseptic lotion, rinse the affected parts and apply 
oxide of zinc ointment on salicylated gauze. You may pack the vagina 



Inflammations of the Female Genital Organs. 39 

with, salicylated gauze covered with the oxide of zinc ointment. The 
antiseptic lotion should be used from two to four times in twenty-four 
hours, according to the severity of the case. 

In the acute form, poultices and sedatives and applications, as the 
lead and opium wash, are indicated, until inflammation abates. 

1£: Plumbi acetas 3 J 

Tinct. Opii 3i v 

Aqua 5iv 

M. et fiat Latio. 
Sig. : First wash the parts with an antiseptic wash, consisting of 
thirty drops of carbolic acid in a pint of warm water. Syringe the 
vagina and vulva, then rinse with hot water (not too hot), then apply 
the above lotion by saturating a piece of absorbent cotton and laying it 
between the labia and over the vulva, and a piece of oiled silk over this, 
keeping the legs apart. During the night, if the inflammation is abat- 
ing, oxide of zinc ointment, or carbolic ointment, will allay the itching, 
and soothe the parts. 

Zinc oxide Z j ss 

Vaseline 3 j 

M. et fiat. Unguentum. 
Apply on lint, after first anointing the parts thoroughly. Use 
white castile soap for cleansing the parts, and rinse and dry the surface. 
Each time after micturition, the parts should be washed and the 
ointment applied. In chronic form, application of nitrate of silver 
is very beneficial. 

Argentum Nitras xii to xv grr 

Aqua I j 

Mix lotion. 

Wash the parts, and apply the lotion for a few minutes ; then 
apply the carbolic ointment for the itching. Oxide of zinc ointment 
will also allay the pruritus. Some recommend carbonate of zinc oint- 
ment. In all cases attention to the ordinary rules of cleanliness is 
necessary. If the vulvo-vaginal glands are implicated, first poultice 
with, hot flaxseed, and then free incision. Wash out the cavity, and 
dress with antiseptic gauze. 

INFLAMMATION OF THE VAGINA. 

Etiology. — Owing to the susceptibility of the vaginal canal, 
and to its associated functions, if there is infection, traumatism 
is paramount. Its relations to the exterior permit in many ways 
the introduction to its recesses of morbid germs, which in the 
absence of a fitting culture medium, may remain in such a state 
of attenuation as to be innocuous. But the canal is the channel of 
outflow for the menstrual blood, together with other secretions, and 
the excretions of the uterus — fluids which may come from the non- 



40 Inflammations of the Female Genital Organs. 

infected uterus. But at times these are appropriate culture mediums, 
and germs already present may quickly multiply and set up inflam- 
mation. I have had a case recently where the vaginal outlet was 
wounded from a fall from a bicycle, the patient falling astride of 
some broken part of the wheel, and puncturing the anterior osse-vaginse. 
Inflammation resulted. Germs were already present, and acute inflam- 
mation followed. Hot vaginal douches, with rest in bed, with lauda- 
num and lead lotion, soon relieved the acute conditions. With aseptic 
dressing, and keeping the bowels in a lax condition, she soon recovered. 

In the virgin the vaginal orifice is protected by a special mem- 
brane, the hymen, so that the entrance of germs is hindered under 
the ordinary conditions of atmospheric pressure; but after parturition 
the orifice is often widened so that air may have easy access, especially 
with the individual in a recumbent position. A lacerated perineum 
will permit such easy access of the air that the woman can not bend 
over without the consciousness of her deplorable condition. 

The lowering of the general systemic powers will often predispose 
to inflammatory conditions of the vaginal canal, with other mucous 
tracts; for instance, measles and scarlet fever, with the exfoliation of 
the epithelium, present a surface easily infected. 

Exposure to cold; excessive coitus; irritant injections and appli- 
cations; the pressure of a pessary; masturbation; oxyurides; the con- 
tact of the vesical or rectal contents, as in fistula ; irritating discharges 
from the direction of the uterus, as in simple or septic metritus or 
carcinoma; the extension of vulvitis, as in children with acid urine, 
or in women with diabetes ; struma ; uncleanliness ; and the traumatism 
and infections attendant upon parturition, or upon abortion, or opera- 
tions — all these are other causes. But perhaps the most important 
,of all is the eternal and everlasting gonorrhea, which our dear good 
women have to be afflicted with, innocently and unconsciously, because 
of the unfaithfulness of their husbands. Vice versa, sometimes, with 
shame upon her.) 

The virulence of this cause, its tendency to wide extension, its 
ability to lie latent for extensive periods in various parts of the genital 
canal, and then reappear in force, make it the most trying factor to 
deal with in vaginal diseases ; its virility seems to be due, it is said, to 
a specific germ, — gonococcus. According to Pozzi, its role was long 
undisputed, the facts proving its preponderating agency appearing to 
be easily demonstrated. Most numerous in the acute stage, rarer in 
the chronic form, the germs increase or diminish in number according 
as the disease is active or latent. They are found in gonorrheal dis- 
charges from the urethra, the glands of Bartholini, the rectum, in 
gonorrheal salpingitis, and in purulent ophthalmia. They have been 
discovered in the blood, and in the articular synovial fluids of patients 
suffering from gonorrheal rheumatism. 

Pathology. — According to C. Ruge, we find this disease commonly 



Inflammations of the Female Genital Organs. 41 

presenting itself under three f orins, simple, granular, and senile vagini- 
tis. A fourth form, present in pregnancy, is added, called emphy- 
sematous. It is rare for the entire surface to be involved, the dis- 
ease presenting itself usually in patches or zones, with healthy tissue 
intervening. If, however, the whole surface is involved, it is in the 
acute stage of gonorrheal, exanthematous, septic, or traumatic inflam- 
mation, dependent, under the last head, upon caustic or scalding hot 
injections. In the simple form the surface is smooth, but here and 
there patches of thickened tissue are seen. In these spots the papilhe 
are swollen, and the neighboring tissues are infiltrated with small cells, 
epithelial layers alone partaking in the proliferation. In the granular 
form, the more common variety, the papillse are infiltrated with small 
cells, and so enlarged that they greatly encroach upon the intervening 
spaces. 

In chronic vaginitis the patches of disease are in places ecchymo- 
tous; in others, denuded of epithelium, leaving raw surfaces, which 
may, when opposed, adhere, tending to obliterate the canal. 

The gaseous form belongs to pregnancy, but it may be present 
without it. The gas is said to be situated in the meshes of the con- 
nective tissue, though the lymphatic capillaries are said to be the place 
of its development. 

DIPHTHERITIC VAGINITIS. 

This is merely the local expression of a general condition, 
and is marked by a greatly-swollen mucous membrane, which is 
more or less covered with neurotic tissue. It belongs to the puer- 
peral state, and to such infectious disorders as measles, smallpox, 
and typhus fever. It is mostly an intense septic process engrafted 
upon a simple inflammation, which may result in extensive loss of 
tissue. Deep-seated inflammatory changes in the subjacent coat are 
seen in consequence of the action of caustic or scalding hot douches 
(accidental events), and localized, deep-seated, ulcerated changes may 
be present in consequence of a neglected pessary. 

Abscesses. — These are the results of either inflammation of a cyst 
of the wall, of traumatism, forceps delivery, or of a development in the 
course of grave febrile states, and may also be present. 

Symptoms. — Acute vaginitis is indicated by a dull pain and a 
sense of fulness in the lower pelvic region. Pain and discomfort 
are increased by micturition, by defecation, and by walking. The dis- 
charge tends to increase rather than to diminish, especially if the case 
be one of gonorrheal origin. The gonorrheal symptoms are burning 
pain in urinating, and vesical tenesmus, which indicates, with fair 
certainty, the causative agent to be gonorrhea. Also may be mentioned 
the presence of inguinal pain and tenderness, due to the implication 
of the inguinal glands. An examination shows the vaginal canal to 
be sensitive, to be hot and swollen, and, at a later period, roughened. 



42 Inflammations of the Female Genital Organs. 

If the urethra be involved, it will be found thickened and tender, and 
a pressure along its course, from within outwards, may drive a drop 
of pus from the meatus. Pus from this quarter is said to be con- 
clusive evidence of gonorrhea. If the bladder be infected, pressure 
upon the anterior vaginal wall will quickly reveal the fact by the 
marked increase in pain which is produced. Inspection may show the 
presence of acute vulvitis ; and, if so, the orifice of the vagina, the ori- 
fice of the vulvo-vaginal glands (especially in gonorrhea), the vesti- 
bule, and the meatus are the parts chiefly involved. All will be cov- 
ered by a muco-purulent or purulent discharge. If the vagina can be 
inspected, its walls will be found covered with a similar secretion, under 
which, as in the vulva, the tissue is seen to be swollen and of a deepened 
red color. 

An acute vaginitis may pass into a chronic vaginitis, if the con- 
ditions be neglected, if the patient be of enfeebled constitution, or if 
the disease be gonorrheal. If the disease is from gonorrhea, it may 
be latent in its places of retreat, — the posterior and anterior fornices 
discharge — leucorrhea. It may follow the acute stage, but most usually 
adequate irritation is forthcoming. 

Chronic vaginitis presents no special local symptoms other than 
discharge — leucorrhea. It may follow the acute stage, but most usually 
is from the first a sub-acute or chronic process. Such vaginitis devel- 
ops in consequence of the discharge from the uterus, or as the result of 
senile changes. In senile vaginitis this discharge is sero-purulent, and 
yellowish, and occasionally brownish, from admixture with blood. 

Leucorrhea originating in the vagina may be thin and whitish, or 
thick and yellowish, and purulent. The former is indicative of the 
milder grades ; the latter shows the more severe ones. 

The most striking development of leucorrhea is seen in fat. 
lithsemic women, and in strumous subjects, and is often rebellious to 
treatment. If a dirty or ill-fitting pessary is used, the discharge will 
be indicative of the kind of lesion produced ; for, in the event of ulcera- 
tion of the wall, a purulent or even blood-stained flow may appear. 
And just here it is well to mention that, following the use of douches 
which are too hot, or those which contain an excess of caustic ingredi- 
ents, such as carbolic acid, and following certain septic and exanthe- 
matous disorders, the discharge soon becomes purulent, and perhaps 
bloody, and may also contain shreds of the exfoliated epithelial cover- 
ing of the vagina. 

A simple vaginitis rarely involves the general health: but if it 
causes profuse and prolonged discharge of any kind, especially if it is 
purulent, it will surely depress the general health. This will be man- 
ifested by loss of energy, by gastric disturbances, and perhaps by con- 
stipation and loss of nerve control. 

Diagnosis. — Simple vaginitis is not infectious. Gonorrheal vag- 
initis is always infectious. It is not always easy to distinguish one 



Inflammations of the Female Genital Organs. 43 

form of vaginitis from another, and jet the fact that one variety is 
infections is enough to render a distinction important. 

Gonorrheal vaginitis is marked by the sndden onset, the virulence, 
and course of the disease, as well as the prompt implication of the ure- 
thra, and perhaps of the bladder, the involvement of the vulvo-vaginal 
ducts and glands, and later by the tendency of the disease to invade the 
uterus and to extend to the adnea. The development of conjunctivitis 
also points to the gonorrheal nature of the disease, and in the absence of 
pregnancy the appearance of vegetation in the vagina is additional 
proof in the same direction. 

Inflammation of the vagina due to cold or to catarrhal conditions 
of the mucous membrane is infectious, and can be transmitted from 
the wife to the husband. The author had a case of that kind. The 
wife had an acute cold, temperature 100 degrees Fahr., had a watery 
discharge from the vagina; and the husband, too, had a cold, but no 
fever; under the existing conditions cohabiting was indulged in, and 
in a very short time the husband had symptoms of gonorrhea, as his 
physicians informed him. His wife was about seven months along in 
pregnancy at the time. Upon her husband's return from the physi- 
cian's office, he made known his condition to her, and asked her, "What 
does this mean?" She, in turn, said to him that she wanted him to 
answer that question, as he knew her condition, and that she had always 
been a faithful and loving wife. He replied that he knew that he had 
never been otherwise than true to his marriage vows. The author was 
sent for to examine the wife, and give her diagnosis of the case. Upon 
examination, I found vaginal inflammation, with an acrid and profuse 
watery discharge, and temperature 100 degrees Fahr., and all the other 
symptoms of an acute cold. The assurance of the contagion was made 
known to him, and with the proper treatment she soon recovered ; also 
the husband. Advice was given to them to occupy separate beds when 
either of them had an acute cold. The treatment prescribed was qui- 
nine, small doses of calomel, followed with a saline laxative and hot 
vaginal douches, with a little carbolic acid in the douche, and rest in bed 
till well. The husband soon recovered from his cold, and the supposed 
gonorrhea was relieved. This occurred ten years ago, and there has 
never been any sign of a return of the trouble in either of them since. 

Simple vaginitis is easily controlled and cured by keeping the 
patient at rest, by freely moving the bowels with mild cathartics, viz., 

Calomel 1-10 gr. 

Soda 1 gr. 

Given every hour for five hours. 

In six hours after the last dose of calomel has been administered, a 
dose of castor oil, or a dose of Epsom or Rochelle salts, may be given to 
move the bowels freely. Give hot vaginal douches. The temperature 
of the water should be about 105 degrees to 110 degrees Fahr., and about 



44 Inflammations of the Female Genital Organs. 

one gallon should be used three times a day. The patient should use 
it lying on her back. To the hot douche may be added from two to 
three teaspoonf uls of borax to one gallon of water. The patient should 
take a tonic of iron, quinine, and strychnia. 

$: (J. Wyeth & Bros.) 

Elixir Ferri, et Quinse Sulphas, et Strychnse 6 oz. 
Sig.: Teaspoonful, for an adult, after meals, in a wine glass of 
water. 

In gonorrheal vaginitis, or inflammation of the vagina, rest in bed, 
and give half -grain doses of mild chloride of mercury, with two grains 
of soda, two hours apart, until three doses have been taken. In eight 
hours take a heaping teaspoonful of Epsom salts in a half tumbler of 
water, to move the bowels freely. Give hot vaginal douches, the temper- 
ature of the water 100 degrees Eahr., with bichloride of mercury in 
the strength of 1 to 10,000. The douche nozzle should be glass or hard 
rubber. One gallon of the antiseptic water should be used three times 
in twenty-four hours, the patient lying on her back. If the introduc- 
tion of the nozzle is painful, apply a six per cent solution of cocaine on 
a bit of absorbent cotton, at the ostium vaginas, for a few minutes, and 
the nozzle can be made to pass in easily. Or anoint the nozzle with 
cocaine ointment, and it will relieve the pain. Keep the bowels free 
with saline mixture of Rochelle and Epsom salts. As soon as acute 
symptoms have been abated, Doctor Polk advises the vagina to be 
washed with soap and warm water, using the fingers, or, if possible, a 
sponge upon a holder, to reach the inequalities of the vaginal surface, 
cocaine being used to lessen the pain if necessary. Then introduce 
a Ferguson's speculum, and, beginning at the cervix, paint over the 
entire surface, as the speculum is slowly withdrawn, with a solution 
of bichloride of mercury, 1 to 1,000. Then wash out the vagina with 
warm water, re-introduce the speculum, and place in position a piece of 
sterilized gauze of three or four thicknesses, the gauze to reach from 
the posterior fornix to the ostium vaginae. By this measure the vaginal 
walls are kept apart, and free drainage is provided for. This treat- 
ment to be repeated daily until the disease is conquered. If at a later 
period the tissues should need stimulation, then paint the surface with 
tincture of iodine. 

In the chronic form of vaginitis the author has found the galvanic 
current very beneficial. The vagina is first washed with an antiseptic 
solution (if not gonorrhea) or carbolic acid douche (acidi-carbolici 3ij, 
water 0). Then bits of absorbent cotton are packed around the uterus, 
covering it with the cotton, which has been wet with warm carbolized 
water. As the speculum is withdrawn, pack in the absorbent cotton 
till the vagina is filled down to the ostium-vaginal. Place a broad, flat 
electrode over the abdomen, just above the pubis, covered with several 
thicknesses of absorbent lint, it being made positive, and place a small, 



Inflammations of the Female Genital Organs. 45 

round electrode — carbon, zinc, or aluminum is preferred — about the 
center of the cotton packing, using care that the negative pole is insu- 
lated with rubber, so that the labia do not touch the electrode. Give 
from twenty to fifty milliamperes, if it is bearable. The treatment 
should be from ten to twenty minutes. Remove the cotton, make an 
application of nitrate of silver, from ten to twenty grains to the ounce 
of water, then lay in several thicknesses of salicylated gauze, covered 
with oxide of zinc ointment, being careful to place it around the uterus, 
keeping the vaginal walls apart, and having a string attached to the 
strip of gauze, and extending to the outside of the ostium-vagina. 
This treatment may be continued daily until the patient is relieved, 
when the application of the galvanic current need not be applied more 
than two or three times a week; but the hot carbolized douche may 
be given daily, with nitrate of silver solution applied, and followed 
with oxide of zinc ointment covering the salicylated gauze, placed as 
above described, to prevent the vaginal walls from touching. The 
patient should have a nutritious diet, take tonic of iron, quinine, and 
sulphate of strychnine. Wyeth's Elixir is a good tonic, given as 
above prescribed, and keeping the bowels regular. If there is struma 
or oxyurides, use the means prescribed for pin-worms ; or if struma, 
give cod-liver oil and tonic. 

URETHRITIS. 

This occurs in cases of gonorrheal vaginitis. Doctor Polk rec- 
ommends washing out the urethral canal with a 1 to 20,000 solution 
of bichloride of mercury, using a small, glass-nozzle syringe. This 
should be repeated every day if necessary. The author has found 
it will give relief to wash out this canal night and morning with cupri- 
sulphas, from gr. ss to gr. 1, to the ounce of water, warm. Then rinse 
with sterilized water, washing the meatus after micturition, and apply- 
ing oxide of zinc ointment. Diluents are useful. Flaxseed tea, with 
infusion of buchu, if taken at intervals of two or three hours, and 
salicylate of soda, five grains taken three times a day till the patient 
is relieved, are beneficial in keeping the urine in a favorable condition. 
Small doses of quinine, from one to two grains, given at the time that 
the salicylate of soda is administered, are also very beneficial. Stim- 
ulating diet and stimulants must not be indulged in. Milk diet is 
preferable; oatmeal gruel, or corn-meal gruel, chicken soup, milk 
toast, eggs in milk twice a day, are the best diet in all inflammations 
of the pelvic organs while in the acute stages. 

In deep-seated inflammations of the vaginal wall, the first step is 
to reduce the inflammation and relieve the pain. Give hot vaginal 
douches, with boracic acid, one teaspoonf ul to one quart of water. The 
patient should be in a recumbent position. Anodyne suppositories 
should be given by the rectum, or vagina, or by the mouth, as deemed 
appropriate. 



46 Inflammations of the Female Genital Organs. 

The vaginal walls should be kept apart as the inflammation sub- 
sides, to prevent adhesions between the walls, or, where sloughs have 
occurred, to prevent atresia. Keep the surfaces apart by strips of 
gauze soaked in mild astringent solutions. Acid sulphurous, — oz. ij to 
water oz. iv, — is a most excellent solution for this purpose. Wash the 
sloughs with a small syringeful of water, letting it remain in contact 
with the affected part a moment, and then dry the parts, after which 
use a strip of gauze thickly covered with oxide of zinc ointment, to keep 
the surfaces apart. After using the sulphurous solution, if stimulation 
of the affected parts is necessary, nitrate of silver wash, ten to twenty 
grains to the ounce of water, may be used. Never use the wash cold ; 
warm washes give more comfort to the patient; the cold produces a 
shock. When a warm solution is used, the patients do not complain of 
pain. 

In gonorrheal vaginitis urethritis occurs as a part of the gonorrheal 
form. The urethritis is best treated with an application of a four or 
six per cent solution of cocaine, with a small, glass-nozzle syringe. Fol- 
low this with a wash made of sulphate of copper, one to two grains of 
sulphate of copper to one ounce of water. I have often found one-half 
grain of sulphate of copper to one ounce of water to be strong enough to 
effect a cure. First cleanse the parts with boracic acid in hot water, and 
syringe the urethra with boric solution, twenty grains to one ounce of 
water; then rinse with hot water, and apply the sulphate of copper 
wash ; after which dip a small piece of absorbent cotton in an oil 
lotion, — linseed oil four ounces, spirits of turpentine one drachm, — 
and apply to the urethra. The urethra should be treated three times 
in twenty-four hours, in the first stage of the inflammation, till the 
inflammation abates, after which night and morning will be often 
enough to use the copper solution. 

Corrosive sublimate is used by most all specialists for irrigating 
the urethral canal, in the strength of 1 to 20,000, and repeated every 
day if necessary. The administration of diluents is necessary, also 
non-irritating diet; use milk, malted milk, rice soup, oatmeal gruel. 
If the urine is acid, five grains of salicylate of sodium taken in half a 
teacup of flaxseed tea, three times a clay between meals, acts well in 
keeping the urine from being irritable. To be taken until relieved. 

In all deep-seated inflammations of the vaginal wall, a biborate 
of sodium douche should be used every four to six hours. When inflam- 
mation abates, keep the vaginal walls apart with gauze soaked in a mild 
astringent solution. An application of nitrate of silver solution, ten 
to fifteen grains to the ounce of water, is better; then dip the strips 
of gauze in linseed oil, as above prescribed, and lay them in, well up 
around the uterus and along the vaginal wall, keeping the walls apart 
to prevent adhesions. 

Abscesses will have to be treated by free incisions, douching the 
canal with antiseptic douches and dressings of iodoform, or bichloride, 



Inflammations of the Female Genital Organs. 47 

or salicylated gauze. In all cases of inflammation of the vaginal canal, 
tonics are necessary to prevent unfavorable reaction upon the general 
system. Glide's pepto-mangan of iron, with a little strychnae, is an 
excellent tonic. 

(Glide's) Pepto-manganate 5xii 

Tr. nux vomica 3 iss 

M. et Sig. : Dessert-spoonful to a tablespoonful after meals, in a 
wineglass of milk or water. 

INFLAMMATION OF THE UTERUS. 

There are various agencies which cause metritis and endo- 
metritis. Germs gain access to the uterus through the vag- 
inal canal, as in case of vaginitis due to gonorrhea. Auto- 
infection, growing of the negligence of careless doctors and nurses 
in allowing decomposed blood or decidual material to be retained, 
should not escape notice. Infection resulting from a combination of 
causes may find a resting-place in the cervical canal. The fornices of 
the vagina likewise afford refuge for such products. Other causes of 
greater importance, because more common, are the microbes common 
to inflammation elsewhere, such as in the surgical infections in ery- 
sipelas, diphtheria, and as in scarlet fever and measles; septic infec- 
tion from wounds, as in case of abortion: also from puerperal sep- 
ticaemia caused by different germs. 

Violent congestion of the uterus, such as occurs in acute suppres- 
sion of menstruation, and in prolonged congestion growing out of flex- 
ions and versions of the uterus, especially when these malpositions 
are bound down by adhesions, are prominent factors in producing 
inflammation of the uterus. The irritation of the organs incident to 
the action of stenosia in retarding the escape of purulent blood, is 
another cause ; also the irritation of excessive coitus, especially at the 
time of menstrual congestion. 

• Accidents which are classed under the head of traumatism are 
patent for evil. Of these, injuries from labor and abortion stand first 
in gravity. Operations upon the cervix which lack in precaution 
against sepsis, are often conclusive as to their influence ; also improperly 
cleansed sound, and occasionally the action of cold douches, if taken 
at the time of menstruation. 

The inflammation about the cervix, due to ill-fitting pessaries or 
neglected pessaries and lack of cleanliness, will easily involve the deeper 
parts of the uterus ; also any inflammation of the vagina, no matter 
how induced. 

In scrofula, constitutional syphilis, extreme lithasmia, chlorosis, 
and anaemic states of the blood, the resistance of the mucous tracts in 
general is lowered, so that agents of disease easily resisted under better 
conditions are here potent for evil. The influence of such conditions 



48 Inflammations of the Female Genital Organs. 

in retarding cure is equally evident, and active constitutional treat- 
ment is called for, as well as local measures. 

Symptoms of Metritis and Endometritis. — The symptoms increase 
with the depth and extent of the lesion. In simple acute endometritis 
they may be comparatively insignificant. There will be a sense of 
fulness in the pelvis, which will be more pronounced if there is an 
arrest of the menstrual flow, but which is relieved should the flow come 
on. Frequent micturition and rectal tenesmus may be present, and 
slight malaise and want of appetite. 

In more severe cases the above symptoms are more pronounced, and 
there is dull, deep-seated pelvic pain, — backache, — in the upper sacral 
region, and aching pains down the inside of the thighs. All these 
local symptoms are increased by motion, micturition, movement of the 
bowels, and coughing. Slight fever will be present, with a loss of appe- 
tite, and a tendency to constipation. 

Septic cases, or blood poisoning, may occur after improperly per- 
formed operations, and especially after abortions and labor cases, and 
they present the most aggravated and pronounced symptoms. Blood 
poisoning from abortion and from labor presents itself by a chill, more 
or less pronounced, and general disturbance of the whole system, fol- 
lowed by a rapid rise of temperature, which lasts for a few hours, then 
falls and rises again at a later period. The elevations are more fre- 
quent in the later hours of the day. If the inflammation extends to 
the peritoneal covering through the uterus, the phenomena of local 
peritonitis are directly added ; if through the Fallopian tubes, the evi- 
dence of tubal disease appears, to be followed by those of local peri- 
tonitis. Extreme symptoms indicative of septic absorption and con- 
stitutional infection may develop, such as would come from absorption 
of the poison through the lymphatic carriers, or the scattering of infected 
thrombi through the body. The extension of a septic endometritis and 
metritis in cases of absorption and labor, in all the ways just mentioned, 
is a common event in consequence of neglect ; but in the non-pregnant 
uterus even a septic inflammation travels onwards, as a rule, more eas- 
ily by the way of the tubes than through other channels, so that in such 
cases the phenomena of salpingitis and peritonitis are more prominent 
than those of septic absorption alone. The extreme symptoms, how- 
ever, do not belong to the history of acute endometritis and metritis 
met with in the non-pregnant uterus. Salpingitis and local peritonitis, 
with their particular evidences, represent the extreme of extension in 
such cases, the poison of gonorrhea being responsible for most of the 
cases. 

Symptoms. — Pressure upwards upon the cervix causes pain, as a 
rule ; the tenderness of the pelvic region is such that the uterus can not 
be satisfactorily mapped out ; and if it can be, it is, as a rule, slightly 
enlarged. The tenderness is often diffused over the entire pelvic area, 
or nearly so. When dependent upon vaginitis, the outer surface of the 



Inflammations of the Female Genital Organs. 49 

cervix will be deep red, and covered with niuco-purulent or purulent dis- 
charge, often bleeding to touch. 

In septic inflammation, especially following operations, abortions, 
or labor, in addition to traumatism incident to such conditions, the 
cervix is much softened, enlarged, and of a deeper color. There may 
be a thick, ichorous, bloody discharge flowing from the cervix, which 
may or may not have the odor of decomposition. 

These are especially pronounced features after abortion or labor. 
In the latter conditions, gray patches of necrosed tissues may sometimes 
be seen. This is the so-called diphtheritic type of inflammation already 
mentioned. 

Diagnosis. — Inquiry into the symptoms and signs will always 
reveal this lesion in the non-pregnant uterus, and, with few exceptions, 
the same statement is true of the uterus after labor and abortion. 
Occasionally it begins so insidiously, and with such a resemblance to 
malarial infection, that one may be deceived ; and if, as often is the 
case, no pain, no tenderness, and no odor of decomposition in the dis- 
charges be present, the deception may be complete. As a rule, such 
cases are of late development ; but, early or late, they are dangerous. If 
it is malaria, the free action of quinine should make the differentiation. 
The mammary glands may be inflamed, and careful examination of the 
breasts failing to reveal the cause, the uterus should be carefully exam- 
ined in its interior, and treated. 

The mere absence of lochial discharge from the vagina is a suspi- 
cious event in these cases, for it generally means retention, by obstruc- 
tion from flexure of the uterus or other causes ; but if a discharge is 
present, its freedom from odor of decomposition is not a safe guide. 
The condition of the uterus as a whole is of some service, because arrest 
of involution is an accompaniment of all these lesions. In all suspi- 
cious cases it is proper to give antiseptic treatment of the interior of 
the uterus. It is safer in all such cases to take the risk of interference 
rather than that of delay. It is said by eminent wr iters that, for rea- 
sons dependent upon the depth, the degree, and the rate of infection, 
twenty-four hours should be the outside limit of delay of this antiseptic 
treatment, which will be spoken of later on. 

Prognosis. — There is danger to life and danger to the organ. In 
simple acute endometritis and metritis life is rarely endangered ; but in 
the septic forms of the disease it commonly is, either through general 
peritonitis or through general septic infection. 

The integrity of the organ is always endangered, but the danger 
is in proportion to the severity of the inflammatory process. In the 
milder forms it is only slight, but is pronounced in the graver forms. 
This results in part from the chronic changes in the uterus itself, the 
offspring of severe acute processes, and in part from the implication 
of the adnexa and surroundings of the uterus, — implications in the 
shape of tubal and ovarian diseases and peritoneal adhesions, which, so 



50 Inflammations of the Female Genital Organs. 

long as they exist, riSay render impossible the return of the uterus to 
its normal state. 

The influence of all this upon menstruation and child-bearing is 
self-evident. It is said by eminent and experienced physicians that 
the prognosis as regards life in the milder forms of this lesion is good ; 
in the graver forms it is serious, and may be very bad. As regards 
recovery of normal functions and structure, it is largely dependent upon 
the resultant complications. The question of prognosis turns as much 
upon treatment as upon the original nature of the disease. The prin- 
ciple of antisepsis, prompt and intelligent treatment, improves to a 
wonderful degree the prognosis in all cases, no matter how grave at the 
outset. 

Treatment. — The milder forms of acute endometritis and metritis 
are best treated by rest in bed, together with free purgation with saline 
cathartics, and copious hot vaginal douches, temperature from 110 
degrees to 115 degrees Fahr. At least four quarts of hot water should 
be used at a time. They should be taken with the patient in a recum- 
bent position, lying on the back, with a bed-pan beneath the buttocks. 
They should be given once every three or four hours for at least twenty- 
four or thirty hours. A rapid depletion can be secured through free 
scarification of the cervix, which, if done in conjunction with a warm 
douche, temperature 106 degrees Fahr., will insure sufficient bleeding 
to aid materially in arresting the disease. As soon as the acute symp- 
toms have been controlled, cotton tampons soaked in glycerine and ich- 
thyol should be placed against the cervix daily. By this means we 
still further aid resolutions, and by the support used add to the patient's 
comfort. The douching and the introduction of the tampons can be 
managed, in case of necessity, by the patient and her nurse, after some 
little instruction, but the scarifications can be properly done only by 
the physician. The cervix may be exposed by means of a speculum, 
and then, after cleansing its surfaces carefully, and scarifying freely 
into its depths at four or five places, keep up the bleeding by a flow of 
warm water, as already noted. Should the blood continue to flow too 
]ong, a hot douche— 115 degrees Fahr. — will speedily control it. Hot 
flaxseed poultices, applied over the hypogastrium, will control the pain 
sufficiently to render unnecessary the use of an opiate ; but if they can 
not be omitted, then use them as a rectal suppository, one or two doses 
being amply sufficient for any ordinary case. One-grain suppository 
of opium by the rectum, once in eight hours, till relieved. 

The more aggravated forms of endometritis and metritis are met 
with in gonorrhea. They should be supplemented with measures 
directed to the interior of the uterus. 

If vaginitis is present, the treatment appropriate to the disease in 
the canal should form a part of the procedure ; for, so long as it remains 
here, reinflection of the uterus may take place. The cavity of this organ 
should be treated upon the same principles that govern the specific treat- 



Inflammations of the Female Genital Organs. 51 

nient of gonorrheal urethritis in either sex. As the internal os of the 
uterus in all these eases of metritis is relaxed, and even somewhat open, 
the interior of the organ is easily reached, but not with the requisite 
freedom, unless in the presence of an anaesthetic, especially if the case 
be one of a patient who has not borne children, for the pain incident 
to proper treatment of the uterus in acute gonorrheal metritis and endo- 
metritis is generally greater than can be endured ; therefore anaesthesia 
is necessary. The cervix should be dilated, so as to admit the smaller- 
sized uterine speculum, through which the canal should then be copi- 
ously irrigated with a solution of bichloride of mercury, 1 to 3,000. 
A quart should be run through from a fountain syringe, and then a strip 
of sterilized gauze (cheesecloth) should be packed into the cavity, its 
free end protruding into the vagina. Xo curetting, as a rule, is needed 
in these gonorrheal cases, as, in spite of the utmost care, in some opera- 
tions, and most complete antisepsia. salpingitis has followed curetting. 
Therefore a less energetic course is recommended by eminent special- 
ists. Careful cleansing, mild antiseptics, and thorough drainage give 
the best results. 

At the end of twenty-four hours, or on the subsidence of the 
symptoms, the irrigation may be repeated and the gauze renewed, this 
time without an anesthesia. The open state of the internal os will 
easily permit this, and in subsequent treatments, creolin, owing to its 
lubricity, will palliate the introduction of the gauze, which drains 
better than bichloride; to this end, therefore, the gauze is soaked in a 
solution of that substance prior to the introduction. From one to three 
or four treatments of this kind may be needed, the symptoms and signs, 
as in other acute processes, being our guide. 

SEPTIC ENDOMETRITIS AXE> METRITIS OCCURRING TS THE XOX- 
PREGXAXT UTERES, AETER OPERATION. 

For instance, such accidents as happen from negligence on 
the part of the operator, proper antisepsis having been omitted. 
In this event, prompt and energetic measures are urgent. The 
cut surfaces upon the cervix should be exposed, and freely cauter- 
ized with pure carbolic acid. The internal os should be dilated, the 
cavity of the uterus freely irrigated with the bichloride of mercury 
solution, — 1 to 3,000. — and the cavity of the uterus should then be 
packed with sterilized gauze, curettage rarely being required. The 
wounded surfaces above mentioned should be kept apart by sterilized 
gauze, and this gauze must be kept in place by the same kind of gauze 
packed in the vagina. If the symptoms subside, the packing in the 
vagina may be removed in forty-eight hours, but that in the uterus 
should not be disturbed for three or four days. It then should be 
withdrawn, if not already expelled, and the interior of the uterus need 
not be again entered. The vaginal douching should be commenced as 
soon as the gauze packing has been removed from the vaginal canal, and 



/ 



52 Inflammations of the Female Genital Organs. 

kept up three times a day with carbolic acid in the douche, until the 
uterine packing has been removed; then the glycerine tampon may be 
used, as recommended for depletion. At a later period the cut sur- 
faces may be dealt with by direct application of astringents or cauter- 
ants, or by operation, as is deemed best. In the event of a persistence 
of unfavorable symptoms, the course to be followed is the same as in 
septic inflammation following abortion, which will now be quoted from 
one of the leading medical text-books which has been our guide. 

SEPTIC INFLAMMATIONS FOLLOWING ABORTIONS AND LABORS. 

"We find ourselves in the presence of not only the gravest 
form of the disorder, but a very common one, so common, 
in fact, that it is hardly too much to say that most of 
these cases of uterine inflammations, met with in practise, 
spring from it." In fact, it is almost a daily occurrence that 
we meet with it. What has been said concerning its prognosis, war- 
rants the above statement, and points also to the urgent need for early 
recognition and prompt treatment. Prompt action means the arrest of 
the terrible disorder, the speedy cure of the patient, with the preserva- 
tion of her fecundity. Delayed action means the extension of the 
disease, which in time means a general infection of the uterus and 
inflammation of the adnexa, with all that such a grade of inflam- 
mation therein implies. But further than all this, delayed action 
means septic peritonitis or general septic infection through the 
lymphatics, or perhaps a pysemis. Radical surgical measures should, 
therefore, be promptly applied. Eo time should be lost in attacking 
the uterus. Its cavity should be freely curetted, the sharp curette 
being employed, aided by a double curette or placental forceps, so that 
all debris may be scraped away and removed. In certain cases, where 
but little tenderness is present, the fingers, or if the uterus be large and 
flabby, two fingers instead of the curette, may be used to remove the 
decidual debris. The method of procedure in these cases is of sufficient 
importance, however, to demand something more than a passing notice. 
The following detailed description is therefore submitted: a As a rule, 
anesthesia is advisable, because thoroughness is doubtful without it, and 
without thoroughness failure may be expected." 

We take it for granted that the patient's toilet is in readiness for 
the operation, and, after the patient has been anesthetized, "shave the 
parts, cleanse the vulva, the vagina, the cervix, and the cervical canal 
carefully, using for this purpose the tincture of green soap and plenty 
of sterilized water. For the washing of these parts employ the fingers 
or a soft brush, aided, if necessary, by a wad of gauze in the jaws of 
a pair of long-handled forceps. Now rinse with warm sterilized water. 
Finishing this preliminary, irrigate the cavity of the uterus freely, 
first dilating the internal os, if it is not already sufficiently opened to 
permit this. If the uterus be large, the irrigation can be conducted 



Inflammations of the Female Genital Organs. 53 

suitably with only a glass tube (Chamberlain's), but if it be small, as 
after early abortion, some provision should be made for the return now 
of the fluid as is called for in the non-pregnant uterus, the uterine 
speculum and metallic-nozzle tube being the preferable combination of 
instruments employed for this purpose. The solution to be used is 
bichloride of mercury, — 1 to 2,000. 

"Finishing this irrigation, the curettage should next be done, the 
fingers being introduced from time to time to make sure that all the 
debris has been removed. It may be possible to do this last work with 
the fingers alone, as has already been intimated; but the combination 
of the sharp curette and the fingers is useful, and, under anesthesia, 
easily made. To facilitate the removal of the dislodged debris from 
the uterine cavity, the double curette forceps or the placenta forceps is 
very useful. The sharp curette is to be preferred at all times to the 
dull, for the same reason that a sharp knife is preferable to a dull one. 
A minimum amount of pressure accomplishes our purpose here, if a 
sharp instrument is used; a maximum amount is needed with a dull 
instrument, and such pressure is far more likely to drive such an instru- 
ment through the softened uterine wall than the force requisite with 
the sharp instrument. Let the sharp curette, therefore, be used, 
employing a firm but light touch, checking its results by an occasional 
exploration with the fingers to examine nodular regions, which seem 
to call for the more energetic application of the instrument. A second 
copious irrigation with bichloride solution, above mentioned, should 
immediately follow curettage, the solution being 115° to 120° Fahr., 
if there be excessive hemorrhage. There is always free bleeding in 
these cases, and occasionally the blood spurts forth as if from some 
large vessel. But little time need be given, however, to the checking 
of the bleeding by this method, for the reason that the succeeding step 
in the treatment will do so promptly. This consists in packing the 
uterus fully and firmly with sterilized gauze. In a large uterus, having 
a well-open canal, this can be quickly done by using the curette forceps 
as a dresser. By means of it a long strip of the gauze, folded length- 
wise half a dozen times, is passed in length by length, carefully pack- 
ing it away, first in one cornu, then in the other, then at the fundus, 
and so on down to the external os, through which into the vagina the 
free end is finally brought. The vagina is then packed loosely, first 
around the cervix, and then down to the ostium vaginas. If the uterus 
be small, as in earlier abortions, the irrigation and the packing can be 
best done through the uterine speculum, as in inflammation of the non- 
pregnant uterus, the strips of gauze in such cases being of about four 
thicknesses, folded to the width of the index finger, and of sufficient 
length to enable one piece to fill completely the uterine cavity. 

"In all septic cases, one may expect a chill and a febrile reaction 
to follow the above treatment; but the temperature quickly falls, and 
the subsequent progress of the case, provided it be early attacked, is gen- 



54 Inflammations of the Female Genital Organs. 

erallj toward a prompt and complete recovery." The author adds that 
while the chill is on, hot fomentations over the heart, and a hypo- 
dermic injection of nitro-glycerine — one of Wyeth & Bros.' tablets 
— will cut short the chill, and add comfort to the patient; and hot- 
water bottles should be placed about the feet. When the chill abates, 
the fomentation over the heart can be removed. a The packing of the 
vagina should be removed at the end of twenty-four hours, a warm, 
cleansing douching of a saturated solution of boric acid being given 
twice in twenty-four hours. At the end of from forty-eight to seventy- 
two hours, the uterine packing may be removed in all these septic cases, 
and if no fever be present, the cavity of the uterus need not be again 
entered ; but if the temperature is still elevated, then remove the pack- 
ing at the end of twenty-four hours, irrigate the cavity again, and apply 
fresh gauze. This may be necessary. 

"In certain rare cases, where the poison is of intense virulence, 
the condition of the patient, in spite of the above treatment, may 
approximate to that in which the interior of the uterus has been of 
too long standing or neglected, in which, therefore, general infection, 
with possibly a peritonitis, has supervened. One should not despair, 
however. The cleansing and drainage should be continued. The 
author uses bichloride of mercury — 1 to 3,000 or 5,000 — for the 
uterine douche, every twenty-four or forty-eight hours, according to the 
virulence of the case, and leaving out the gauze can get a freer drain- 
age in cases of abortion ; however, if the uterus has a tendency to con- 
tract and permit the putrid secretions to pass out, insertion of the 
gauze into the uterine cavity will have to be resorted to." 

In the event of approaching the case for the first time after gen- 
eral infection or even salpingitis and peritonitis have supervened, the 
directions for curettage and packing already mentioned should be car- 
ried out, seemingly desperate cases not infrequently yielding to these 
measures. 

The general measures of treatment called for in septic cases consist 
of mild purgatives with salines ; the relief of pain by opiates ; and the 
careful administration of easily-digested food, preferably milk and its 
preparations, such as koumiss and matzoon, or other forms of concen- 
trated food, soft-boiled eggs and milk, and the free administration of 
stimulants, such as champagne, brandy, or whisky, aided by strychnse. 
Prolonged convalescence may be expected in all severe cases which are 
fortunate enough to recover. This appears to be due to changes in the 
lymphatic system and in the blood-making glands. Malnutrition and 
anemia are common results, and the obstinacy with which such states 
are frequently maintained calls for a constant supervision as to food, 
tonic, and hygiene, extending in some cases over several years. 

The gravest perplexity in surgery arises, however, in connection 
with all cases of general septic infection and peritonitis, the per- 
plexity occurring in consequence of the possibilities of further and 



Inflammations of the Female Genital Organs. 55 

more extended operation procedures. The removal of the infected 
uterus either through the vagina, or by coeliotomy, would offer the surest 
relief, could the shock of so grave an operation be controlled. But 
patients infected with a general sepsis rarely withstand any abdominal 
or even pelvic operation. II pyemia be already present, coeliotomy 
can offer no possible hope. 

The Treatment of Chronic Endometritis and Metritis. — Com- 
mencing with the cervix, erosion of the vaginal face of an untorn cer- 
vix, depending, as such cases usually do, upon vaginitis of some kind, 
should be treated with a view to this fact; therefore, the vaginitis 
should be treated along the line already laid out. At the same time, 
the eroded surface should be treated with the galvanic current of elec- 
tricity. The positive pole should be made to cover the erosion by 
moving it over the eroded surface, keeping the electrode applied from 
two to five minutes on each part of the diseased surface. After the 
galvanic seance, then apply the tincture of iodine (Churchill's). If 
there are any cysts, use the negative pole over the cyst instead of the 
positive. Give from twenty to fifty milliamperes ; or what is better, 
attach to the negative rheorphore an electric needle (platinum pre- 
ferred), place over the hypogastric region a flat electrode covered with 
several thicknesses of lint, puncture the cyst to the bottom, turn on 
from live to ten to twenty milliamperes, if necessary, till you observe 
that the bubbles or foam around the needle are sufficient to open the cyst. 
Seance from one to two minutes is usually time enough for each cyst. 
In some cases it may take fixe minutes' treatment where there is low 
amperage. After the cysts have been punctured with the electro- 
galvanic needles, then wash the cervix with a solution of boric acid, and 
apply Churchill's tincture of iodine. One puncture is all that is 
needed, if well done, to effect a cure of the cyst. The iodine may be 
applied every day, or every other day, until the erosion disappars. 

When you do not have the galvanic battery to assist in the rapid 
depletion of the congested uterus, scarification, aided by the action of 
hot douches and tamonades of cotton wool soaked in a saturated solu- 
tion of borax in glycerine or ichthyole and glycerine, will soon produce 
the desired result. Indurated surfaces, after scarification, should be 
cleansed, then painted with Churchill's tincture of iodine, or the cysts 
evacuated and cauterized with nitrate of silver. A daily use of the 
glycerine tampons, together with hot douches — 115° Fahr. — need not 
extend over three or four weeks, especially if aided by the scarification 
and the local applications above mentioned. Then, if further treatment 
is needed, it should take the form of some one of the operative measures 
which belong to the domain of surgery. 

Whenever possible, the integrity of the uterus should be restored, 
and this precaution is especially called for in the face of posterior dis- 
placements of the uterus, for without a good cervical projection into 
the vagina the leverage necessary to the proper action of a pessary is 
difficult to obtain. 



56 Inflammations of the Female Genital Organs. 

In chronic inflammation of the corpus uteri, where the stage 
of induration has become fixed from long continuance of the infiltra- 
tion, every case is stubborn, but the larger number of these can be cured, 
and all can be benefited by means of the galvanic current of electricity, 
properly applied. 

The cases that respond most readily to treatment are those of sub- 
involution, this condition being largely an arrest of a normal process, 
rather than a pathological change. As a part of this state, we have the 
cases of the hemorrhagic form, in which decidual remnants are the focus 
of the endometrical change. In this latter condition we have the stage 
of induration, and particularly such cases as develop in connection with 
the menopause, or present membranous exfoliations. We also have that 
rare condition, super-involution. All these cases are very much prone to 
stubbornness. We have cases of stenosis, with flexions and versions, in 
which mechanical problems are presented as a part of the therapeutic 
question to be solved, and cases long in the stage of infiltration, in which 
the glandular form of endometritis predominates as a muco-purulent 
discharge, with perhaps a lessening of the menstrual discharge, charac- 
terizing them. Apart from these cases, we have cases associated with 
chronic disease of the adnexa, or peritoneal adhesions, especially where 
the adhesions have fixed the uterus in an abnormal position, — for 
instance, retroversion and latero-version. Such cases belong to the 
subject of salpingitis, mentioned farther on. 

The appropriate treatment of a chronically inflamed uterus can only 
be had when we bring ourselves to that point, viewing this organ as a 
hollow structure, having communication with the exterior ; wherein it 
is seen that it is amenable only through the same kind of treatment 
which prevails in the treatment of other cavities similarly situated. 

The sooner the treatment is begun the better, because when the 
stage of induration is accomplished, such is the condition of the mucous 
membrane and walls, owing to connective tissue sclerosis, that a cure 
is difficult. 

The most appropriate measures are cleansing the uterine cavity, 
removing exuberant and diseased tissue, and checking its reproduction 
by direct application of re-agents, aided by enforced depletion and 
efficient drainage ; and lastly, the chemical action of the galvanic cur- 
rent aids wonderfully in helping the case along to a successful issue. 

All this is best accomplished by irrigation, by curettage, by direct 
use of iodine, or some similar re-agent, and by forcibly distending the 
entire cavity with sterilized gauze, bringing, for the purpose of irriga- 
tion, the ends of the gauze through the cervical canal into the vagina. 
The treatment is the same as that already treated of in conjunction 
with the treatment of acute metritis, but there are minor differences, 
rendering necessary a reconsideration of the matter in connection with 
chronic metritis. 

Such treatment ranks with the minor pelvic operations, and should 



Inflammations of the Female Genital Organs. 57 

always be so considered, and carried out with as much regard to asepsis 
and cleanliness as prevails in a vaginal hysterectomy, as without this 
precaution a salpingitis and peritonitis may be produced. When 
done properly, nothing but good can come of it. 

Treatment. — Curettage, caustic applications, drainage. These 
measures demand anesthesia. 

The bowels should be thoroughly moved the day before the opera- 
tion with some kind of laxative. The morning of the operation, the 
patient should not eat any breakfast, except in some cases, where a cup 
of coffee early in the morning relieves headache; it should be given 
black, without cream or sugar. 

The village physician works at a disadvantage in not having 
trained nurses to prepare the room antiseptically for the operation, 
which is very important in all minor surgery. The reader is referred 
to the chapter on that subject. 

After the patient is well under an anesthetic, the vulva and vagina 
are thoroughly cleansed with green soap and warm water, as already 
suggested in connection with the treatment for acute disorders. 

Dilation of the cervix is the next step. Some operators prefer 
Hank's graduated dilator of rubber; others use Steel's or Emmett's 
dilators. The author first uses Hank's, then Emmett's, Hank's dilator 
being placed in boiling water in reach of the operator. By beginning 
with the smallest, it is often necessary to use a sound to get the exact 
curve of the canal; then bend the smallest dilator to fit the curved 
canal, holding the uterus steady with the Volsella forceps. The rub- 
ber dilator is made to pass into the cervix, then removed, and is replaced 
with another, till the third smallest size has been made to enter the 
cervix; then dilate with Steel's or Emmett's. This is followed by the 
introduction of the uterine speculum, through which the cavity of the 
uterus is copiously flushed with a warm bichloride of mercury 
solution, 1 to 2,000, to the amount of one or two pints. 

Curettage is the next step. " This is performed with a sharp 
curette (Simm's), aided by Emmett's double curette forceps. The 
entire cavity is scraped, first with the sharp curette, the persistence and 
vigor with which this is done being governed by the conditions present, 
the hemorrhagic form calling for greater persistence and vigor than 
recent sub-involution and endometritis of simple stenosis, or in anti- 
flexion. The anterior wall, the posterior wall, the lateral sulci where 
these two come together, the fundus, and the recesses of the cornu are 
scraped in turn. Special attention should be paid to the fundus and 
the cornu. The double-curette forceps will aid here, using this instru- 
ment to pinch or bite off all excrescences, and using them finally to clean 
out all debris from the cavity as a whole. Keep the uterus fixed with 
a Volsella, during the time curetting is going on, so that thorough work 
may be done with the curette, guarding, however, against accidents, 
such as penetrating the wall, which has been done. The vigor with 



58 Inflammations of the Female Genital Organs. 

which the curette is applied should he iu proportion to the resistance 
offered by the tissues. After curettage is completed, reintroduce the 
uterine speculum, and again copiously irrigate the cavity with some 
warm bichloride of mercury solution of the same strength as that first 
employed. At the outset of the operation, the surgeon places some 
gauze in a bichloride of mercury solution — 1 to 5000, a strip about four 
feet in length, folded four times, so as to present a width throughout 
about equal to that of the index finger, which has been prepared for the 
cavity. An applicator is passed into the uterus through the speculum. 
Catching an end upon a simi-tampon screw or with an applicator, the 
gauze is passed into the uterus through the speculum, length by length, 
packing it away, first in one cornu, then in the other, then at the 
fundus, then down, step by step, until the cervix is reached. To this 
end, the speculum is gradually withdrawn as the packing encroaches 
upon it. Reaching the internal os the packing ceases. The free end 
of the gauze is then brought out through the cervix into the vagina. 
The excess is now either cut off or coiled up against the cervix. The 
vagina is now loosely filled with large pieces of gauze, this step com- 
pleting the operation. At the end of forty-eight hours, the vaginal 
packing is removed; the vagina is now douched twice a day, until the 
uterine packing is removed. This should be done on the fifth day, a 
final vaginal douche being then given, unless the douches be continued 
from time to time for cleanliness. In some cases the uterus expels 
the internal part as early as the second or third day, but as some of 
it always remains, and by so doing insures the potency of the cervix 
and therefore drainage, it should not be disturbed until the day speci- 
fied. Seven or eight days before the menstrual period is the time of 
election for this operation, it being that at which the greatest amount 
of depletion can be secured; and as depletion is the essence of this 
treatment, nothing should be omitted which will insure it. The fact 
that menstruation may begin while the gauze is in place, constitutes no 
objection to the selection of this time, for the gauze will do no harm, 
many patients having carried it through a period without an unusual 
symptom in consequence. 

Cases with stenosis, flexion, or version, require correction of these 
defects ; otherwise the endometritis and metritis will be produced. 
The flexion is best cured by an operation, and the version may be cured 
by a well-fitting pessary or an operation, and the stenosis by an opera- 
tion, and, as some specialists recommend, the wearing of the cervical 
or uterus stem, all of which may be done in conjunction with dilata- 
tion, curettage, and packing, as those measures consume very little 
time. The author has had very successful results in the cure of 
stenosis by means of the galvanic current of electricity. The positive 
pole is placed in the cavity of the cervix, the negative over the hypo- 
gastric region; milliamperes are given in sufficient number to get the 
pathological effect, the operator being the judge. Usually from thirty 



Inflammations of the Female Genital Organs. 59 

to forty milliamperes will be sufficient, seance being from seven to ten 
minutes, once every third day, till a cure is effected. Many operators 
curette thoroughly the second time in cases of stenosis, then treat with 
Churchill's tincture of iodine, and finally pack as above mentioned, 
and a relapse is very improbable. However, such cases are often 
found very stubborn. In all cases of sub-involution and fibroid dis- 
ease with a sub-mucous growth, the galvanic current of electricity will 
alleviate the pain and aid in the checking of the hemorrhage, with the 
use of hot vaginal douches, and in case of urgent bleeding, ergot and 
hydrastis may be employed, and rest in bed should be insisted upon. 

In condition of super-involution of the uterus, when the uterus 
is yet soft, the faradic current of electricity is very serviceable, but 
when induration supervenes, the galvanic current should be given 
alternate days with the faradic current. The patient should be treated 
daily. 

Dysmenorrhea is controlled by the means of both currents given 
simultaneously, and has proved beneficial in the author's hands. The 
general health should be cared for. Good food, tonics, and rest are 
needed ; keep the bowels regular ; the patient should have some kind of 
occupation to keep her from brooding over her condition, many patients 
being such sufferers from dysmenorrhea that their minds are constantly 
on their condition, and they talk of their expected monthlies almost 
continually. If the patient has some kind of pleasant occupation for 
the diversion of the mind, the treatments are more likely to be 
effective. 

I will here say a word in reference to vaginal massage. In all 
uterine diseases it is unnecessary, and the author believes that if long 
continued in, it would lead to conditions similar to those produced 
by masturbation. 

A good abdominal supporter will give comfort to many of these 
patients who have relaxation of the abdominal muscles. 

The pelvic, lumbo-sacral, and crural pains, which are so annoying 
to many of these patients, and which are most pronounced toward the 
close of the day, are best treated by a hot sitz-bath, taken just before 
the patient retires. I will also add that both currents of electricity 
are very efficacious in the alleviation of the pain, especially the gal- 
vanic current, the positive pole being placed over the seat of pain, and 
the negative over the seat whence the pain seems to radiate, the operator 
judging the course of the nerves affected. Seance, half an hour, if 
necessary, till relieved. Often ten minutes over each seat of pain is 
sufficient length of time. Then paint over where the positive pole was 
placed with tincture of iodine, and put on cotton batting. As much as 
one hundred milliamperes may be given for the relief of pain. 

Obstinate dyspepsia associated with dilatation of the stomach is 
best treated by "lavage" and the galvanic and faradic currents of elec- 
tricity, applied on alternate days, either internallv to the mucous 



60 Inflammations of the Female Genital Organs. 

>iiembrane, or externally where the patient can not admit of the 
stomach tube being passed into the stomach. The internal treatment 
gives quicker results in the author's hands. The positive pole is placed 
over the nape of the neck, and the reorphore from the negative post is 
attached to the aluminum wire, which has been passed through the 
stomach tube, which (the tube) has a closed end, and is interrupted on 
either side of the tube. Be careful that the end of the electrode is 
pushed past the interrupted part down to the end of the tube, which 
must be done before the stomach tube is passed into the stomach. 
Mark the exact length where the reorphore is attached, so that in case 
the patient should, under an excited condition, grasp the tube and pull 
out the wire, you can ascertain whether the wire has been removed 
very far; if it has, the tube will have to be removed, and the wire 
replaced as above described, and re-passed into the stomach, assuring 
the patient that there is no danger so long as the wire does not pass 
through the interrupted tube. The patient having drunk a tumblerful of 
warm water (the water is a good conductor of electricity), the current 
will be conducted to all parts of the stomach from the electric wire by 
the water. Give from ten to twenty milliamperes for catarrh of the 
stomach and for the dilatation. The f aradic current gives quick relief 
in many cases, and is beneficial in all cases when properly applied. 
The faradic current is applied internally in the same manner as the 
galvanic current. 

In cases of nervous dyspepsia, due to chronic endometritis, where 
medicaments have failed to improve the patient's condition, the positive 
pole of the galvanic current is placed over the epigastric region, and the 
negative electrode, of aluminum wire or of platinum, well insulated 
with rubber to nearly the end of the wire, and with a bit of absorbent 
cotton cleverly twisted tightly over the end of the wire, and far 
enough back over the rubber — thinly applied over the rubber — twisted 
tightly to prevent the cotton from slipping off when the wire is removed, 
should be dipped into a solution of boiling-hot boracic acid before it is 
passed into the fundus of the uterus. The electrode must be allowed 
to cool before introducing it into the uterus, and give from twenty to 
forty milliamperes, moving the electrode first to the right cornu, then 
to the left, next to the fundus. The seance should be about two min- 
utes in each place, then remove the electrode down to the internal os, 
and give Hve minutes' treatment; remove the electrode, and make an 
application to the cervix of nitrate of silver — twenty grains to the 
ounce — or an application of Churchill's tincture of iodine. This treat- 
ment should be given every other day for two or three weeks, then once 
every third day till the patient is relieved. 

Less pronounced cases of stomachic disorder call for regulation of 
the diet, stomachic tonics, and for regulation of the bowels. Where 
ordinary exercise can not be taken, general massage, aided by general 
faradization, will prove beneficial, and tonics, for the improvement of 



Inflammations of the Female Genital Organs. 61 

the blood, bearing upon the nervous system, may be indicated; finally, 
freedom from the marital relation, freedom from the cares of the house- 
wife, and a judicious employment of outdoor exercise, will render 
essential service wherever indicated or permissible. 

A concluding word of warning touching upon sterility. No 
treatment can be said to be entirely successful in the diseases of a uterus 
still within the period of full menstruation, unless this blight be over- 
come. The first measure is, to let sexual relations be natural, without 
any removal or disturbance of the secretions deposited by the husband, 
because it is the natural tonic for the vaginal walls and uterus. Any 
one who takes measures for the removal of this procreating material, 
which is God's plan for the production of human life, will have to 
suffer bodily in consequence of the act. 

The writer can say that where nature is allowed to take its natural 
course in sexual relations, with the galvanic current alternately with the 
faradic current of electricity properly applied, with subsequent 
curettage and packing when it is called for, and local applications of 
Churchill's tincture of iodine and hygienic measures of the genitals, the 
best results have been secured in her hands. 



CHAPTER IV. 

INFLAMMATIONS OF THE UTERINE APPENDAGES AND 

PERITONEUM. 

x . PELVIC INFLAMMATION. 

The causes of salpingitis, oophoritis, cellulitis, lymphangitis, and 
pelvic peritonitis, with few exceptions, spring from the uterus. 

Endometritis and metritis may be said to be the causes of the 
above lesions. 

The exceptions are found in a peritonitis developed in connection 
with the growth of "certain ovarian tumors," the origin of which is 
supposed to depend upon conditions within the ovary itself, as, for 
instance, hsematomous of the ovary, dermoid cysts, and the simpler 
ovarian cysts ; and yet the fact already noted in connection with the caus- 
ation of endometritis and metritis should not be forgotten, namely, that 
the pressure of such growths upon the uterus sometimes provokes 
chronic inflammation of the organ, so that the peritonitis may not be 
the direct result of changes originating in the ovary, but rather from 
the uterus, as the source, which, more than any other, stands respon- 
sible for this lesion. 

Acute suppression of menstruation is another extra-uterine cause 
which has been named. After all that has been said concerning the 
causes of the inflammations of the uterus and the endometrium, it is 
found that, while it is possible for any one of them to act so as to pro- 
duce inflammation in the tubes, ovaries, cellular tissues, and peritoneum, 
yet as a fact it is the septic and specific poisons which produce these 
lesions most frequently. 

In the non-pregnant uterus, the premenstrual period is one of 
the greatest susceptibility, while in the uterus recently pregnant, the 
first three days occupy this position. Pregnancy is responsible for a 
larger proportion of the inflammations involving the adnexa than any 
other causes combined, and of these criminal abortion ranks highest 
in point of infection capacity, as it generally represents the extremes of 
septic infection. Other causes may be added to the non-pregnant 
uterus in connection with any traumatism inflicted without due regard 
to antiseptic precaution, such as operations on the cervix, curettage, or 
the use of a dirty sound. The writer had one case of pelvic inflamma- 
tion due to gonorrhea, which spread from the endometrium to the tubes, 
thence to the cellular tissues. 
(62) 



Inflammations of the Uterine Appendages and Peritoneum. 



63 



Dr. W. Polk says: "There can be no question as to the participa- 
tion of the lymphatics and veins in the propagation of sepsis. In 
pyaemia, for instance, the presence of infected thrombi in distant parts 
proves the participation of the veins, while the presence of pus in the 
lymph spaces of the uterine walls, and the lymph-vessels of the broad 
ligaments, shows the position of the lymphatics as channels of infection. 
In sepsis of recently pregnant uteri, the extension to the ovaries and 
peritoneum is by way of the tubes, and also through the lymphatics, but 




Longitudinal Sagittal Section of Woman in Red Position. 
Showing the Various Axes of the Uterine and Vag- 
inal Canal and Pelvic Brim and Vaginal Roof. 



the extension most destructive to the integrity of the ovary and peri- 
toneum is that through the tubes.*' 

The writer had a case of inflammation of the peritoneum and 
cellular tissue due to tuberculosis, which is referred to in the article 
upon tuberculosis. 

Scarlet fever, measles, and smallpox are said to be etiological 
factors. Whether their agency is an indirect one through the medium 
of the vagina and uterus, as already discussed, or a direct one, as mani- 
fested by a direct action of specific poison of a severe form of recent 
inflammation, the tube is enlarged, the increase reaching in some cases 



64 Inflammations of the Uterine Appendages and Peritoneum. 

to the size of the adult's middle finger, or even larger. The fimbriated 
end of the tube may be closed by recent exudation; if it remains open 
or partially open, it gives exit to the muco-purulent exudate from the 
cavity of the tube. Kesolution, it is said, may take place in the severe 
forms, but the tendency is toward the chronic forms. As a rule, both 
tubes are attacked in the severe forms; however, it is more frequently 
the case that one is affected to a greater degree than the other. 

In the virulent septic inflammations following labors and abor- 
tions, the process may terminate fatally too rapidly to admit of any 
operative measures. 

* The Pathology of the Chronic Forms of Salpingitis. — Both tubes 
are commonly involved, one to a greater extent than the other. This 
thickening in mainly interstitial, an inflammation of the entire thick- 
ness of the wall, an interstitial or parenchymatous salpingitis in which 
all the elements participate, but chiefly the connective tissue, the 
changes, in fact, being analogous to those met with under similar con- 
ditions in the wall of the uterus. This interstitial process is most pro- 
nounced when peritonitis is superadded, because the tube is attacked 
both from within and from without. 

Acute exacerbations of all inflammatory processes extend to its 
outer as well as to its inner face. Fever is very common in all earlier 
phases of all cases, or most cases, of chronic salpingitis. The tube, as a 
whole, is much softened. Seen from the operating table, it resembles 
in this particular the structure of the uterus when it suffers a similar 
extension of the acute process to its peritoneal aspect. 

PYOSALPINX. 

The most common is the pus sac, or pyosalpinx. It 
is merely a tube, the walls of which show interstitial inflammation; 
the outer end is closed, and perhaps also the inner end of the tube. 
The closure of the outer end is the common -condition, or it may be 
fixed against the ovary or some adjacent structure. The contraction of 
the inner end is the result of inflammatory adhesion of the opposed 
inner surfaces of the tube, this closure being most common near the 
cornu, but possible at any point of the narrower length of the canal. 
The contractions account for the retention of secretions and exudates 
within the tube, and the accumulation of such substances accounts for 
the enlargement which the ampulla of the tube undergoes. The greater 
enlargements occur as the result of closure of both ends of the tube ; the 
lesser are found in conjunction with a free uterine end, the contents of 
the tube thus having opportunity for escape into the uterus. This 
escape is either a constant leakage, or like an intermittent discharge, 
brought on either by direct contraction of the tube, or by such pressure 
as may be developed in efforts, such as defecation. Direct pressure 
with the fingers will cause the partial evacuation of some of these 
pus sacs. The pus sac, or pyosalpinx, may be bi-lateral or uni-lateral. 



Inflammations of the Uterine Appendages and Peritoneum. 65 

Usually when this condition exists in one tube, salpingitis of some grade 
may be existing in the other tube. 

The common form is a general enlargement of the tube, club- 
shaped at the outer end, tapering gradually towards the uterus, more or 
less convoluted, the conditions being due to the restraining action of 
what may be called the mesosalpinx, the peritoneal attachment to the 
broad ligament, and to its connection with the ovary. 

The tube may be doubled upon itself, such constrictions being 
dependent upon peritoneal adhesions and bands. The greatest develop- 
ment is generally seen in tubes measurably free from constrictions, 
which assume the appearance of pear-shaped cysts, and in general attain 
about the size of the average normal uterus ; in rare cases, such develop- 
ments have been seen to attain to the dimensions of the average foetal 
head. 

Pus in a tube will often remain relatively quiescent for con- 
siderable periods of time, and occasionally, in common with similar 
collections elsewhere, may suffer partial absorption and appear ulti- 
mately as a pultaceous mass. The tendency, however, is to escape, the 
direction of escape being probably most often along the canal of the 
uterus ; next, through the abdominal end of the tube, the fluid forcing 
its way between the agglutinated fimbrse, and also, by the combination 
of stretching and degeneration, an opening is made in the tube wall, 
through which escape of pus occurs. 

The frequent discharge of the pus through the canal into the 
uterus, explains, in part, the fact that such cases are for a time free 
from dangerous symptoms. The tendency is for the tube to refill, thus 
alternately emptying and refilling. This condition may exist for a 
long time, either ending in atrophy of the tube, or by closure of the 
channel of escape result in a complete pus sac. 

Resolution with restoration of function of such a structure is 
thought to be impossible, and the best that can be hoped for is some 
form of atrophic change. In the absence of this change, we may 
expect the contents of such pus sacs to escape outwards. 

In developments which follow the escape of pus towards the peri- 
toneal surface, leakage from the abdominal end of pus tubes is found 
to be common, each escape being accompanied and followed by the 
phenomena of a local peritonitis proportional to the amount and the 
specific virulence of the fluid. Cases originating in septic abortion or 
labors present the most virulent pus; those originating in gonorrheal 
infection rank next ; and all other cases produce, as a rule, less virulent 
forms of pus. The presence of the streptococcus and staphylococcus 
mark the most virulent forms. 

Hydrosalpinx is a cystic enlargement of the tube in which the 
general outlines and dimensions of the organ are in the main similar 
to those found in pyosalpinx. There are, however, radical differences. 
The contents are serous, not purulent, and in many cases as limpid as 

5 



66 Inflammations of the Uterine Appendages and Peritoneum. 

water. It is said that the walls of such sacs have generally lost their 
original anatomical structure, connective tissue taking the place of all 
other. This change is the most pronounced in the mucous and mus- 
cular structures. The wall may be so thin in places as to be trans- 
parent. 

It is found as a bilateral rather than as a unilateral disease, and 
is rarely without the association of strong, well-organized adhesions. 
It is free from the aggressive action characterizing pyosalpinx, tending 
to quiescence, though sometimes to intermittent discharge through the 
canal into the uterus, and finally to absorption, and general atrophy of 
the outer parts of the tube. 

Hsematosalpinx is the remaining cystic development in the tube. 
The treatment is the removal of the tubes in toto.. 

INFLAMMATION OF THE OVARIES. 
ACUTE OOPHORITIS. 

As a rule, both organs are involved — inflammation of the 
ovary. Keatings says, "While oophoritis is mainly a sequence 
of salpingitis, it occurs quite independently of this latter dis- 
order." "But," says he, "whether the initial ovarian lesion begins 
within or without the organ, the ultimate result of the inflammation 
will generally be the same, because outside implications will extend to 
the interior, and inside will generally find its way to the exterior, the 
lymphatics in both instances being the route of intercommunication. 

Primary Causes. — The interstitial development is, no doubt, the 
rule in all cases arising from acute suppression of menstruation. If 
the type of inflammation be purulent, pus cells will predominate. 
Along with all are the usual inflammatory hyperemia and oedemia. 
Beginning as an interstitial process, the same element pervades the 
organ, the predominance of the simpler inflammatory elements upon 
the one hand, or those indicative of suppuration upon the other, being 
governed by the presence or absence of the so-called septic element in 
the causation. 

Purulent infiltration leads to the development of abscesses, coales- 
cence of which may convert the ovary into a complete pus sac, nothing 
remaining but the tunica albuginse. 

The treatment is to remove the pus sac, which comes under the 
head of surgery. 

CHRONIC OOPHORITIS. 

The common changes are atrophy and cystic degeneration. 
Atrophy may occur independently of outside size, and having a 
shriveled appearance. In the cystic form, the albuginse is thickened, 
and the organ is filled with cysts intermixed with comparatively 
normal follicles. Some of these cysts may be so large as to occupy 



Inflammations of the Uterine Appendages and Peritoneum. 67 

nearly the whole of the ovary, and these no doubt represent the begin- 
ning of an ovarian tnrnor. It is said that in the absence of decided 
thickening of the albuginse, these ovaries continue their function, a 
sufficient amount of normal tissue being present to permit this. 

LYMPHANGITIS. 

It is said that some implication of the lymphatics is a 
factor in all inflammations, and the more abundant the supply of 
these vessels, the more pronounced the implication. The infecting 
element has the most potent influence in producing the lesion. We 
have the simple and septic inflammation of the lymphatics. The two 
extremes of the inflammatory process are seen in the pregnant and the 
non-pregnant uterus and their appendages. 

It is said that in the inflammation of the non-pregnant uterus and 
its appendages, it is so subordinated to the lesion which begat it, that 
close inspection is needed to recognize it. 

In the septic inflammation of the recently pregnant uterus, we 
find the lymph spaces and lymph vessels of the uterus, of the append- 
ages, and of the broad ligaments, filled with purulent fluid. The 
more advanced the pregnancy, and the more virulent the poison, the 
more pronounced are the evidences of lymphangitis. The vessels and 
spaces are more or less crowded with the bacteria of sepsis, this crowd- 
ing being so great in the worst cases as practically to choke up these 
vessels. The role played by the lymphatics as channels of infection 
has been spoken of, and it has been shown how this is subordinate to 
the state of the uterus and the degree of virulence of the infecting 
agents. As those statements agree with the phenomena of inflamma- 
tion as developed in other tissues of the body, we must conclude that a 
distinctly septic element must be present in order that a lymphangitis 
may produce a metritis, a salpingitis, an oophoritis, a cellulitis, or a 
peritonitis. 

CELLULITIS. 

Cellulitis is dependent on lymphangitis, and consequently may 
appear as an associate of an inflammation in any part of the gen- 
ital tract. Doctor Polk is disposed to ignore the initiation of this 
disorder by the so-called direct extension of the infecting element to 
the cellular tissues, and also that through the veins, as both are 
subordinate to lymphatic extension occurring after these vessels have 
become choked with infecting elements. 

Cellulitis belongs essentially to septic processes, — those in which 
putrefactive germs figure. The frequent presence of these agents 
already noted, in the inflammation of the recently pregnant uterus, and 
next the abundant supply of lymphatics in such uteri, readily accounts 
for the additional fact that cellulitis is a more common and a more 



68 Inflammations of the Uterine Appendages and Peritoneum. 

pronounced associate of the inflammation of abortion and labors, than 
of that developed in the non-pregnant nterus. 

It consists of a serous exudate in the meshes of the connective 
tissue, which is accompanied by active cell-proliferation. This process 
may resolve, may pass into a suppurative stage, or may lead to organ- 
ization of new connective tissue, with subsequent contraction, leading 
to shrinkage and sclerosis in the infected region. It is generally a 
circumscribed process. If the initiating inflammation be of virulent 
type, the process will be purulent from the outset ; it will not be cir- 
cumscribed, but will tend, on the contrary, to widespread extension, 
with necrosis of tissue. 

CHRONIC CELLULITIS. 

It has been witnessed from the operating table, by Doctor 
Polk and others, and also by the writer, "that it presents itself 
either as the organized, sclerosed, and shrunken remnant of an 
acute process, or as an adjunct of a similar process going on in an 
adjacent organ. Should the adjacent organ become purulent, and the 
route of evacuation be toward the area of cellulitis, this area, assuming 
the purulent type, will become a circumscribed abscess. This change 
is witnessed in conjunction with the migration of the pus from a tube, 
from an ovary, or from a loculus of pus encysted within the peritoneal 
cavity. Such abscesses are, therefore, indirect, rather than direct, 
formations, and are present in all cases in which pus from the source 
above named makes its way into the broad ligaments or through the 
pelvic-wall floor." 

It is found that cellulitis is often dependent upon salpingitis and 
oophoritis, more than on metritis. Its gravest forms come from a septic 
metritis, as, for instance, a metritis from abortion and labors. The 
broad ligaments are commonly the seat of cellulitis, but as it is an 
accompaniment, to some degree, of inflammation wherever seated, it 
is to be found beneath all inflammations which rest near the connective 
tissue plane of the pelvis. As it is viewed from the operating table, 
we find it in the utero-sacral ligaments, and around and about the 
lower segment of the uterus. It commonly appears as a diffuse infil- 
tration extending along the upper border of the broad ligaments, fol- 
lowing the lines of the lymphatic vessels coming from the body of the 
uterus. If it forms an abscess, it attains large dimensions ; otherwise, 
its tendency is to resolution. Its conversion into an abscess is occasion- 
ally the case, the change being a common accompaniment of puerperal 
septic inflammation, which usually ends fatally. 

Cellulitis occurring in conjunction with lesion of the cervix and 
upper vagina, may lead to suppuration, as after traumatism of forced 
delivery; "or it may result in connective tissue increase, with subse- 
quent organization and sclerosis, the condition extending widely 
through the lower areas of the pelvic connective tissue." 



Inflammations of the Uterine Appendages and Peritoneum. 69 



PERITONITIS. 



Its source of infection is the cavities of the uterus, the tubes, and 
occasionally the ovaries. 

Peritonitis is presented in three general types, — the serous, the 
fibrinous, and the suppurative. The serous is the simplest, and 
appears as a serous transudation following upon the initial infection, 
which is a starting-point for all. "It is said to be possible for such a 
transudation to be unaccompanied by any exudation or lymph, and to 
be free, therefore, from any associated adhesions or bands of new tis- 
sues ; but, as a fact, some degree of lymph formation may be expected." 

The writer has seen this exudate serum and lymph absorbed, leav- 
ing scarcely a trace, and then, on the other hand, cases have come under 
observation where the lymph underwent organization, presenting itself 
then as membranous formation, which in some places is thick, and 
in others filmy, forming sacs or pockets, which imprison more or less 
of the exudate. These accumulations of serous fluid may disappear 
with the subsidence of the slight inflammation provoking them, leaving 
the false membranes, which by subsequent contraction may become 
a serious hindrance to the organ to which they are attached. Then, on 
the other hand, it is said that "any serous exudate, through the influ- 
ence of an additional inflammatory impulse, may assume the character- 
istics of a sero-purulent exudate, in which event its membranous 
incapsulation is increased in thickness and density, the combination of 
the two tending to the production of an encysted abscess. 

"The fibrinous variety of this exudate may form a part of the 
serous, as already indicated. It is thought that a fibrinous exudate 
may be the predominating feature from the first. We find here the 
peritoneal surface covered to a greater or less extent with a coating of 
lymph, the serous exudate being a subordinate feature. The tendency 
of such condition is toward organization, with the creation of strong 
and well-formed areas of new connective tissue, which serve to bind 
together the opposed faces of the organs or tissues involved." 

From this source we may have every affected organ bound down 
by adhesions, fastening the appendages in abnormal positions, and the 
fixation of the uterus in the position of retroversion or retroflexion, or 
anteversion, or in the contraction and fixation of coils of the intestines. 
In some cases the adhesions may be so extensive as not only to imprison 
the uterus and its appendages, binding them to the floor of the pelvis, 
but even to binding together every coil of the intestines situated below 
the umbilicum. Great suffering prevails from these adhesions involv- 
ing the intestines, owing to interference with the movement of the 
bowels. 

The suppurative type of peritonitis presents itself in two general 
forms. "It is first found in a diffuse process in which pus predom- 
inates, with more or less incompletely-formed lymph as an associate; 



70 Inflammations of the Uterine Appendages and Peritoneum. 

for instance, the condition is best seen in conjunction with the general 
septic peritonitis of the puerperal state.' 7 

The second form is common as an associate of pyosalpinx, and of 
ovarian abscess, and occasionally it occurs from suppurative cellulitis. 
It is incapsulated within peritoneal adhesions, and while it is generally 
a direct development from an exudation upon the peritoneal surface, 
in conjunction with a salpingitis, or an oophoritis, it is also a formation 
secondary to ovarian abscesses, to pyosalpinx, a ruptured extra- 
uterine fcetation, to a peritoneal hsematocele, and perhaps to a cellu- 
pelvic abscess. It springs from a pyosalpinx, an ovarian abscess, from 
a^ suppurative inflammation of the peritoneal surface, or the same 
process as a sequence with intra-peritoneal extravasations of extra- 
uterine pregnancy or hsematocele. a The collections of pus are to be 
found in the posterior and lower portions of the true pelvis, but the 
pelvic abscess is sometimes found wherever the inflamed end of a fal- 
lopian tube may lie; it sometimes occurs in the iliac fossa, especially 
in puerperal cases, and in conjunction with fibroid tumors." The 
writer witnessed such a case from an operating table, a short time ago, 
at the Waldeck Sanitarium, on Sutter Street, San Francisco. Opera- 
tion performed by Dr. Thorn, Sr. Patient recovered. 

The most common form of pelvic abscess is said to be derived 
from, and associated with, pyosalpinx. It is met with frequently in 
the region of the cul-de-sac and that of the lateral fossa. Its tendency 
is to discharge itself either into the vagina or into the rectum. It may 
perforate the broad ligament and discharge into the bladder. It may 
empty itself through the abdominal wall above Poupart's ligament. 
There are cases on record where they occasionally will make their way 
through the iliac fossa, and discharge below Poupart's ligament, upon 
the anterior aspect of the thigh. From what has beerj written con- 
cerning the action of the peritoneum in connection with these collec- 
tions of pus, it is plain that its tendency is toward the constriction of 
a strong limited layer of adhesions around and about all such collec- 
tions, no matter what their seat. In this way bad cases of pyosalpinx 
and ovarian abscess receive dense coats of false membrane, and all 
collections of pus in the pelvis are cut off from the free peritoneal 
cavity, it being roofed over, as it were, by the same formation of false 
membrane. 

"In the event of sudden rupture towards the general peritoneal 
cavity, the phenomena of acute general peritonitis may be expected, but 
the extent and virulence of such a peritonitis are more dependent upon 
the specific characteristics of the escaping pus than upon the mere fact 
that it is pus. Cases of pelvic abscesses which have an antecedent 
history of puerperal sepsin, may be viewed as most dangerous." 

Symptoms and Signs. — We shall observe the distinction between 
the. acute, and the chronic, and the suppurative forms of the inflamma- 
tion, as they are presented, and will deal with the signs and the ques- 



Inflammations of the Uterine Appendages and Peritoneum. 71 

tion of differential diagnosis. We will endeavor to note the distinctions 
made by different authors as we go along. 

ACUTE SALPINGITIS. 

In the non-septic forms, the symptoms are the same as those of 
endometritis, already alluded to. If we find general constitutional 
disturbances, pain and fulness over the arch of the pelvis, and if this 
increase be in the direction of the iliac region, we may look for the 
appendages being implicated, the temperature amounting to about 101 
degrees Fahr., pulse rate 105 degrees to 110 degrees, the respiration 
very little changed. 

Motion increases the pain, and the patient is more comfortable 
remaining still. This is the simplest form of salpingitis. 

The above is generally found when the disease is a sequence of 
a single acute endometritis or metritis. In milder forms there are 
exceptions, where the lesions are the result of an acute suppressed 
menstruation. The pelvic pain is apt to be virulent from the outset, 
extending over the hypogastric and iliac region; pain radiates to the 
back and down the thighs, accompanied with a sense of fulness over 
the lower part of the pelvis ; may be attended by constipation. 

The patient can not move without greatly adding to the pain, and 
the pulse, temperature, and respiration are increased. The pulse may 
reach 110 to 120, temperature 102 degrees Fahr., respiration 26 to 28. 

A sharp attack of pelvic peritonitis may accompany the menstrual 
flow, and this suppression, together with the cause producing it, indi- 
cates the source from which it comes. If the attack be uncomplicated 
by a prior endometritis or salpingitis, it may be expected to subside 
within a few days, but in proportion to its severity it may be a fore- 
runner of a chronic inflammation, which may annoy the patient for 
many subsequent years. 

The symptoms of the mild form of acute pelvic inflammation will 
prevail for a period varying from ten days to a month, after which, if 
they continue, they belong to the chronic inflammatory disorder. 

The gonorrheal form of this disorder differs but little from those 
given above. 

The acute form of the septic inflammation will differ somewhat, 
according to the soil upon which the poison is implanted. If it be 
a non-pregnant uterus upon which traumatism has been inflicted, we 
may have perhaps the history of such traumatism, following which we 
have a chill, with a sudden onset of high fever ; following this, we have 
first hypogastric and iliac pain and fulness upon one or both sides, 
according as the ailment involves one or both sets of appendages. In 
some cases a double involvement prevails here, so that general pelvic 
pain sooner or later predominates. The symptoms may now subside, 
but if no attempt is made to strike at the root of the sepsis, they may be 
expected to persist and to pass within a few days into those of a well- 
marked attack of pelvic peritonitis, or perhaps worse, into a general 
peritonitis, which speedily ends in death. 



72 Inflammations of the Uterine Appendages and Peritoneum. 

The usual termination, however, is in a chronic pelvic inflamma- 
tion, in which the tubes, ovaries, and peritoneum are involved to a 
greater or less degree. If the soil presented be that of a recently 
pregnant uterus, we have the antecedent history, which, if it be a 
natural delivery at term, will excite less suspicion than if it be an 
abortion. But whether it be one or the other, salpingitis and its asso- 
ciate inflammations are ushered in by symptoms which are akin to those 
just named. In most cases the symptoms of acute endometritis and 
metritis are so pronounced that ample warning is given ; in other cases 
the approach of this evil is veiled i nan insidious development which 
demands the closest scrutiny of all puerperal cases. The initial chill 
and subsequent fever may be so slight as to cause but little apprehen- 
sion, but pain, which may be absent over the uterus, soon appears upon 
one or both sides. This may be localized for several days, and if the 
case has a favorable tendency it may so remain. On the other hand, 
it may involve the entire pelvis or may spread to the general abdominal 
cavity, the patient in the one case presenting the phenomena of pelvic 
peritonitis, in the other those of general peritonitis. If it assumes this 
latter phase, death may be expected, but if the symptoms indicate 
restriction to the pelvis, they will end in those symptoms indicating 
chronic inflammation, passing frequently into those belonging to the 
development of an abscess. 

In the more virulent forms of puerperal septic infection the 
symptoms may appear so suddenly, with such an intensity, and be so 
widespread as to unite metritis and general pelvic inflammation in 
one vivid picture. The writer witnessed one case of this kind where 
the temperature rose to 106 degrees after the chill began to pass off, 
and there was no pain complained of. The patient had given birth 
to a child twelve days previous. She had an interstitial growth in the 
wall of the uterus. The labor was normal. She, however, had had 
septic endometritis three years previous to the birth of this child. The 
patient recovered. 

The case above mentioned was one of the benumbed variety of pelvic 
and septic inflammation. The treatment was antiseptic throughout, 
with saline laxatives and ice-bag applied over the abdomen ; first lay two 
thicknesses of flannel over the hypogastric region and then the ice-bags. 
The action of the ice-bags must be watched, and when the temperature 
falls, remove them, leaving the flannel over the pelvic region. Hot 
vaginal douches with bichloride of mercury — 1 to 3,000 — were given 
three times in twenty-four hours; quinine, alternately with salol, was 
given in sufficient doses for the tonic effect of the quinine, and for the 
antiseptic effect of the salol; small doses of mild chloride of mercury 
were given in one to one-fourth-grain doses, occasionally, when the 
indications called for it. 

Summing up the signs pertaining to acute pelvic inflammation, 
we find tenderness and resistance in the affected region. Pressure 
upon the uterus by the examination with the finger in the vagina 



Inflammations of the Uterine Appendages and Peritoneum. 73 

increases the pain ; the mobility of the organ is sooner or later impaired, 
and with much exudate present, may finally be lost. The sense of 
boggy resistance at the site of the inflamed organs generally increases 
until ultimately a well-defined mass is appreciated. This may be only 
on one side of the uterus, or there may be one upon each side. The 
masses are usually near to the uterus, but may be in both or one iliac 
fossae, filling these regions more or less completely, if within the true 
pelvis. The writer has seen it fill the interval between the uterus and 
the pelvic wall, displacing the uterus to the opposite side when single ; 
but if double, it tends to push it forward. The forward displacement 
of the uterus is greatest when the mass or masses invade the cul-de-sac ; 
and this development in the cul-de-sac is greatest when both ovaries 
and tubes are involved. Under such circumstances, the uterus may 
lie imbedded in a mass of exudate, and being pushed forward against 
the symphysis, the entire floor of the pelvis will present a hard surface 
to the examining finger. "This extreme condition of affairs, while 
developing within the confines of the acute stage, is an indication that 
the process is passing either into the chronic or into the suppurative 
form; for while resolution may remove the smaller masses, and cause 
the disappearance of a large portion of the more extended ones, yet 
with the latter a nucleus of indurated tissue will generally remain in 
and about the region of the ovary and the end of the tube, constituting 
a variety of the chromic forms of the ailment. And again, in place of 
resolution, suppuration may soon supervene, a termination by no means 
rare in the septic types which follow abortions and labor." (Professor 
Keating. ) 

Chronic inflammation has no special effect upon the pulse or tem- 
perature, while in the acute inflammation we find a temperature. In 
the chronic form, general nutrition and the nervous system are apt to 
suffer, so that such patients are sufferers of digestive derangement, 
meteorism, and constipation. Neurasthenia, malnutrition, and mus- 
cular weakness may be expected. . Some patients are bedridden invalids, 
while others, who are constitutionally strong, will carry an amount of 
lesion with comparative impunity. 

The special symptom of this ailment can be best presented as 
peculiarities of pain, of menstruation, and of leucorrhea. There is 
more or less pelvic pain and fulness; this feeling increases prior to 
the menstrual flow. The pain is more marked upon one side of 
the uterus, and often on both sides. Motion or any disturbance 
will increase the pain. A full rectum or a full bladder will add 
to the discomfort of the patient. The sciatic, plexus, obturator, and 
crural nerves, and the psoas and iliacus muscles, are said to be affected 
by pressure, which is represented by pain along the course of the 
involved nerves, and painful contraction of the implicated muscles, so 
that a crural neuralgia, together with pain in bending or flexing the 
limb on the affected side, is a common feature of an iliac deposit, and 
sciatic pain is the result of certain deposits in the pelvis. 



74 Inflammations of the Uterine A ppendages and Peritoneum. 

In chronic pelvic inflammation, the patient is often a sufferer from 
dysmenorrhea; it may be irregular, occurring too frequently, or less 
frequent than normal; it may be excessive at any given period, and 
then, again, scanty. 

Physical Signs. — The uterus is generally enlarged, its mobility is 
lessened to a greater or less degree, pressing upwards increases pain, 
and it is displaced from the central position. 

The uterus may be retroverted. or anteverted. The indurated 
masses is a distinctive sign of the affection. The induration may be 
bent upon one side, or it may fill the interval between the uterus and 
the pelvic wall, even encroaching upon the corresponding iliac fossa; 
and again it may present itself on both sides, and, finally, the posterior 
regions as well, the uterus being literally embedded in the mass, which, 
occupying the entire pelvic floor, has pushed the uterus forward against 
the symphysis. Tenderness upon pressure is the rule ; where it is in a 
state of activity, the tenderness is increased. The nervous system is a 
factor here, because where this has developed a hyperesthesia, a com- 
paratively small lesion may present an exaggerated tenderness; yet 
cases are met with, in which in spite of the presence of even wide- 
spread indurations, very little pain or tenderness is complained of. 

It is not easy to account for this fact, especially as such indura- 
tions may be situated indifferently, either at the pelvic floor, or upon 
the wall, or be suspended upon the upper regions of the broad ligament. 
Percussion furnishes us some information. Dulness marks the area of 
the masses, of course; but if an encysted peritoneal accumulation is 
present, such, for instance, as a serous exudate, a lesser degree of rela- 
tive dulness may extend far beyond the mere area of recognizable 
induration. Under these circumstances percussion becomes a valuable 
aid. Inspection, also, is of service in revealing the more general dis- 
tention which the acute exacerbation may present, or the localized dis- 
tention, which may mark the chronic interference with the sigmoid, 
and the rectum, or even with the coils of the small intestines. 

PELVIC ABSCESS. 

Symptoms of Pelvic Abscess. — General symptoms are early indi- 
cators of suppuration. There is, usually, somewhat regular exacerba- 
tion of temperature, and an increase of the pulse and respiration rate. 
The three keeping pace, will show a daily increase in proportion to the 
extent and activity of the suppurative process. These daily exacerba- 
tions are seen to reach as high as 103 degrees to 105 degrees Fahr. for 
temperature ; the pulse 100, 120, or 130 ; and for the respiration, 22 
to 25 to 30. These figures are considered as marking an extreme case. 
Lower figures prevail in the less acute cases, and proper treatment may 
be counted upon to modify them favorably in nearly every instance, as 
a subsidence which reaches below 100 degrees Fahr., for the temper- 
ature, 90 for the pulse, and 20 for the respiration. There may be some 



Inflammations of the Uterine Appendages and Peritoneum. 75 

perspiration, Tree sweating, however, indicates a considerable degree 
of septic infection, and is, therefore, a symptom of gravity. In the 
absence of proper treatment, these symptoms continue to prevail ; appe- 
tite and digestion are seriously impaired, and the result of the com- 
bined influence of the disturbing factors is steady emaciation and loss 
of strength. Such patients, it is needless to say, are in great danger, 
for, apart from the danger of a rupture of the pus sac toward the gen- 
eral peritoneal cavity, and that which pertains to pyaemia, there is 
always before one the steady decline of vital powers incident to all 
forms of prolonged suppuration. A spontaneous favorable termina- 
tion may possibly be reached by a discharge of the pus outward, espe- 
cially if this be through the abdominal wall or through the vagina ; but 
even here the pus sac may remain and continue to refill and discharge, 
perhaps through a tortuous sinus, and the evil effect of persistent 
absorption may exist. This has been seen to discharge by way of the 
intestines ; in this instance faecal gases and solid matter may enter the 
sac, and, keeping up the irritation, may not only aggravate the original 
lesions, but add to its malign influence that which pertains to the 
absorption of faecal poisons. The local symptom of pelvis abscess 
relates to an increase of pain and fulness in the affected region, with 
generally some increase of vesical and, perhaps, rectal irritation. 
Should the abscess point in the direction of either of these organs, there 
will always be increased irritation within them, and should it press 
upon the sciatic plexus or the obturator nerve, pain in the course of 
these nerves may be expected. An abscess located in the iliac fossa 
may be expected to cause some retraction of the thighs and legs of the 
affected side, and it rarely fails to induce pain with the motion of the 
thigh, all being dependent upon the implication of the surface of the 
proas and iliacus muscles. 

Signs of Pelvic Abscess. — As already outlined — first, by aspira- 
tion, and next, that which results from palpation, and from fluctua- 
tion. For such cases, aspiration will suffice. 

Diagnosis of Pelvic Inflammation. — It is necessary to give a dif- 
ferential diagnosis of pelvic inflammation, under two heads. We will 
give the differentiation of pelvic inflammation as a whole, from condi- 
tions which it may simulate ; second, the differentiations, one from the 
other, of the conditions which enter into it. 

The following diseased states may simulate pelvic inflammation: 
Taecal impaction, haeniatocele. cancer, fibroids, psoas, abscess, and 
appendicitis. 

Faecal Impaction. — A good cathartic should precede all pelvic 
and abdominal examinations, which generally removes faecal masses ; 
and a glycerine enema — one to two table spoonfuls of glycerine in one 
pint of warm water — will aid in dispelling faecal masses. As there 
are cases in which this may not be quickly accomplished, or where the 
cathartic has not been administered, such masses are often painful : but 
the outline of the tumorous mass can be felt by careful pressure, and 



76 Inflammations of the Uterine Appendages and Peritoneum. 

the pressure will cause such an indentation that there is not likely to 
be any mistake. An exception is to be made where the impaction is a 
part of organic construction of the gut, where a local peritonitis may 
set up about the impacted mass, preventing the necessary manipulation. 
In such cases, anesthesia will clear this up. 

HAEMATOCELE. 

The history of the case is to be considered, with the appear- 
ance of the tumor, and the sudden development of hematocele, 
which is unlike anything characteristic of pelvic inflammation. Keat- 
ing says: "There is little difference in the signs, for an extensive 
development of inflammation may give appearance and effect quite like 
those pertaining to hematocele, and that, too, no matter at what stage 
of the two conditions the comparison is made. Both are soft at the 
inception, then hard, and later both may soften again. Both are cov- 
ered with peritoneal exudate, so that after all some degree of pelvic 
inflammation enters into every case of hematocele, whether it be intra 
or extra-peritoneal." 

CANCER. 

Cancer is sufficiently self-assertive to be always recognizable 
through some one of the channels of investigation at our command. 

Cancerous tumors of the sigmoid, of the rectum, and the bladder, 
are all indicated by symptoms closely connected with the organs 
involved, so that, although in consequence of a perforating ulcerative 
process developed as a part of the malignant affection in any one of the 
situations mentioned, a localized peritonitis may occur; and although 
this peritonitis may lead to a considerable addition to the general area 
of the original tumor, yet the history of the case, together with the 
characteristic symptoms and signs of intestinal or vesical implication, 
will reveal the essential nature of the ailment. 

FIBROID TUMORS. 

Occasionally a fibroid uterus, small enough to remain in 
the true pelvis, becomes fixed therein by peritonitis, which is gen- 
erally provoked by salpingitis; it is not an uncommon complica- 
tion of fibroids. The appearances presented are then very similar to 
such as may result from a combination of ovarian abscesses or hsema- 
toma, with salpingitis and peritonitis, both being, perhaps, nodular, 
both hard, and both giving a history of recurrent attacks of peritonitis. 
In such conditions the uterine sound is of inestimable value, showing 
a marked increase in the depth of the uterine canal in case of fibroid, 
and little or no increase in the other. Every resource of diagnostic 
method should be brought to bear, if necessary, aspiration through the 
vagina being, beyond question, the most serviceable of all. 

The mobility and outline of such structures, — as pelvic Mamma- 



Inflammations of the Uterine Appendages and Peritoneum. 77 

torj masses and uncomplicated fibroid diseases, — coupled with the 
revelations of the sound, are sufficient for all purposes. 

PSOAS ABSCESSES. 

Dr. W. Polk says: "Pelvic inflammations which implicate 
the psoas and iliacus muscles and the crural nerve, may occasion 
symptoms and signs referable to the lower limb which simulate 
the above conditions, but the absence of spinal symptoms and signs, 
and the fact that a distinct line of induration can be traced from 
the region of the uterus to the iliac fossa, will determine the presence 
of pelvic inflammation. It is only when the two conditions occur in 
the same patient that confusion can arise. One is then liable to fall 
into error, and to infer that only pelvic inflammation is present. The 
exaggeration of the hip symptoms and signs should create suspicion, 
however, and then further inquiry will not only reveal spinal symptoms 
and signs, but will bring out the double history." 

APPENDICITIS. 

It is necessary to give the anatomy of the location of the 
vermiform appendix, or vermiform process, as it is very variable, 
according to regional anatomy, by George McClellan, M. D. The 
vermiform appendix is usually from seven to fifteen centimeters, or from 
three to six inches, in length, and from five to six millimeters, or about 
a quarter of an inch, in diameter. It arises from the lower and pos- 
terior part of the caecum, and terminates in a free rounded blunt end. 
It has a small mesentery of its own, which ties it more or less loosely 
to the back surface of the caecum. It is usually directed upwards in a 
flexuous course toward the termination of the duodenum, but it will be 
found not uncommonly hanging downwards into the right iliac fossa, 
between the caecum and the ilium. Dr. McClellan states that within 
his observation, "where this process has been involved in perityphlitis, 
in consequence of the lodgment of an intestinal concretion or a foreign 
body, and an operation was required for its relief, the position within 
the iliac fossa was noticed." 

As to the inflammation situated within the area of the iliac fossa, 
if this be dependent upon the appendages, there will almost certainly 
be an antecedent history of some condition giving an enlarged uterus, 
such, for instance, as pregnancy, a fibroid uterus, a hsematocele, a hydro- 
cele, or pyometra, because it is said to be quite rare, aside from such 
conditions, for the appendages to rest upon the iliac fossa. The his- 
tory of the case will show further that the exacerbations are connected 
with uterine disturbances, particularly with menstruation. Palpa- 
tion will reveal a connecting induration between the uterus and the 
iliac mass, and also that the mobility of the uterus is impaired as a 
whole. 

The symptoms of appendicitis are more acute, the exacerbations 



78 Inflammations of the Uterine Appendages and Peritoneum. 

are more pronounced, than those associated with inflammation of the 
appendages, and they are commonly more severe, both in their local and 
in their general expression. 

Aspiration, as an aid to diagnosis, is apt to give negative results 
until suppuration occurs. Should fsecal matter be obtained, it would 
be conclusive as to the presence of appendicitis, but pus with simply a 
fsecal odor would not be conclusive, as any purulent collection near a 
large intestine may possess this odor. 

Before turning to the differentiation of the organs which are 
involved in pelvic inflammation of the uterus and appendages, I will 
give a brief history of the causes of appendicitis, from Wood and Fitz, 
for the edification of our sex, because the first question I am asked 
from them is, "What is the cause of appendicitis V 

Etiology. — According to Dr. Toft, the vermiform appendix was 
found diseased in one hundred and ten cases out of three hundred post- 
mortem examinations, and Hawkins found a like condition in sixteen 
out of one hundred autopsies. 

The causes of the great frequency of inflammation of the appendix 
which is indicated by these figures, are due both to congenital pecul- 
iarities of structure and to conditions acquired after birth. Among 
the former are unusual length and abnormal position of the appendix, 
and irregularities in the development of its mesentery, which abnormi- 
ties tend to favor the accumulation of material within the canal. 

The important causes acquired after birth, are adhesions due to a 
localized peritonitis, either proceeding from the appendix or rising else- 
where in the abdomen, in consequence of which the appendix becomes 
adherent, and is prevented from expelling its contents. Most impor- 
tant of all is the presence of fsecal concretions or foreign bodies, the 
former being found in about one-half, and the other in at least one- 
quarter of the cases. Moulded inspissated fseces, however, are found 
often in a normal appendix, and therefore are to be regarded rather as 
a favoring than as the exciting cause of the inflammation. The same 
is true, though to a lesser degree, of the foreign bodies, which are 
various, and include seeds, bristles, worms, shot, beans, pills, and 
gallstones. 

Digestive disturbances, or a strain or jar, such as may take place 
in lifting, jumping, falling, or from a blow, are of etiological impor- 
tance in at least one-third of the cases. Usually, however, an attack 
begins without any obvious exciting cause. Appendicitis occurs oftener 
in males than in females, and especially in healthy youths and young 
adults, although it has been observed in an infant of twenty months, 
and in a person seventy-eight years of age. 

Morbid Anatomy. — The varieties of inflammation which may be 
found in the appendix are the catarrhal, ulcerative, and gangrenous, 
each of which may be circumscribed or diffuse. 

The catarrhal and ulcerative forms of inflammation are acute or 
chronic, and end in resolution, perforation, stenosis, obliteration ; while 



Inflammations of the Uterine Appendages and Peritoneum. 79 

the gangrenous variety always ends in perforation. The appearance 
of catarrhal appendicitis is the same as that of catarrhal inflammation 
elsewhere in the intestines. But the tendency of all inflammation of 
the appendix is so strong to a rapid extension to the sub-mucous, mus- 
cular, and peritoneal coats, that the term "infectious" has been sug- 
gested by Morris to indicate the nature of acute appendicitis. 

Symptoms. — The recognition of symptoms of appendicitis is by 
no means so frequent as might be inferred from the observations of 
Toft and Hawkins, of the prevalence of the disease. It is certain that 
many attacks of appendicitis are so latent as to produce either no 
symptoms, or such slight disturbance as not to attract particular atten- 
tion. The practitioner, however, is concerned with those instances in 
which positive symptoms are present. Such cases may be conveniently 
grouped under acute and chronic appendicitis. 

Acute appendicitis is characterized by abdominal pain, tenderness 
in the right iliac fossa, elevation of temperature, circumscribed resist- 
ance, and digestive disturbance. Most important is the unexpected 
occurrence of the pain in a person previously well, or suffering for a 
day or two from slight malaise, manifested by loss of appetite, nausea, 
constipation, or diarrhea. Although the pain is generally unexpected, 
it may follow an obvious exciting cause, as an error in diet, a jar, a 
strain, or the action of a purgative, and is sometimes associated with a 
chill or chilliness. It varies in character from a sense of discomfort 
to one of agony, compelling the patient to make a sudden outcry. It 
is usually constant, though sometimes paroxysmal. At the outset it is 
often referred to the abdomen in general, or to the hypogastric, umbil- 
ical, epigastric, or other region, but is soon localized in the right iliac 
fossa. 

Of greater diagnostic importance than pain, is localized tender- 
ness, often exquisite, produced by either superficial or deep pressure. 
The seat of the tenderness is usually found in the iliac fossa, within a 
radius of two inches from the anterior-superior spine of the ilium. 
McBurney has observed it oftenest near the outer edge of the right 
muscle, on a line between the naval and the anterior-superior spine of 
the ilium, — McBurney's point, — with the variations, however, in the 
position to the appendix, the point of greatest tenderness may be found 
elsewhere in the right iliac fossa, or even in the umbilical or lumbar 
region, in the iliac fossa, in the groin, or in the pelvis. 

Elevation of temperature, however slight, is a most significant 
symptom of appendicitis, since it indicates the inflammatory origin of 
the pain and tenderness. Within twenty-four hours after the onset of 
the pain, the temperature may be less than 100 degrees Fahr., or it 
may rapidly rise above this point, especially in children, and through- 
out mild cases of appendicitis it may not exceed 101 degrees Fahr. 
In general, in a typical case of appendicitis an elevation of two or three 
degrees is to be expected, but a subnormal temperature may be present 



80 Inflammations of the Uterine Appendages and Peritoneum. 

in the severest cases of acute appendicitis, in which general peritonitis 
is present from the outset. The pulse is quickened, usually, in pro- 
portion to the elevation of temperature, but is much accelerated in the 
grave cases, even when the temperature is low. 

^Resistance on palpation of the wall of the right iliac fossa is 
next in importance to localized tenderness and elevation of tempera- 
ture. During the first twenty-four hours after the incipient pain, 
especially when severe, the abdomen is often flattened, even retracted, 
and the tense right rectus abdominis muscle resists palpation, render- 
ing it difficult, if not impossible, to distinguish a localized tumor if 
present. The abdomen, however, soon becomes distended and tym- 
panitic, and though at first only moderately swollen, it is afterwards 
considerably so. 

The circumscribed induration in the region of the appendix soon 
becomes apparent, and is found usually in the "right iliac fossa, below 
the line extending from the anterior-superior spine of the ilium, to 
the navel, nearer the former, and two finger-breadths above Poup art's 
ligament." The position of the induration varies, however, in accord- 
ance with the difference in the position of the appendix, already men- 
tioned. This induration is sometimes superficial, in close proximity 
to the anterior abdominal wall, but is more often deep-seated, and cov- 
ered by the usually distended and tympanitic caecum, or by the dis- 
tended coils of the ilium. The induration may be diffused or circum- 
scribed, and if originally diffused, tends eventually to become defined. 
It sometimes represents a resistant mass of the size and shape of the 
little finger, or is ovoid in outline. This circumscribed resistance is 
due to the swollen appendix, and the surrounding peritoneal exudation, 
upon the abundance of which depends the size of the tumor. Fluctua- 
tion becomes apparent only at a late stage in the disease, when the 
exudation is so increased in quantity as to lie near the anterior 
abdominal wall. 

The respiration is but little affected. There is loss of appetite, 
and vomiting is a frequent occurrence at the outset, but is usually tem- 
porary, unless general peritonitis is present. Diarrhea sometimes 
precedes the attack, though it is generally absent, except at a late stage 
in protracted cases. Constipation is the rule. Increased frequency 
of micturition is sometimes an early symptom, but retention of urine, 
perhaps requiring the use of a catheter, not infrequently takes place 
for a while after the first twenty-four hours. The urine is high-colored, 
and may be albuminous. In the further progress of acute appendicitis, 
the tendency is toward resolution or perforation, with the resulting 
localized peritoneal abscess or general peritonitis. According to the 
experience of most physicians in large practise, the termination in 
resolution is frequent. 

In the mild cases of appendicitis terminating in resolution, the 
pain soon becomes localized, and is easily relieved by hot or cold 



Inflammations of the Uterine Appendages and Peritoneum. 81 

applications, or by small doses of morphine, although occasional twinges 
of pain occur. The temperature is usually slightly higher at each 
evening observation than on the previous day, until the third or fourth 
day, when it drops, often suddenly, sometimes gradually, to nearly the 
normal point. The abdomen is only moderately distended, and there 
is usually but little nausea or vomiting. The localized induration in 
the region of the appendix shows no tendency to increase in size, and 
its sensitiveness rapidly diminishes. 

Although the action of the bowels is arrested, and catheterization 
may be necessary to empty the bladder, the intestinal peristalsis and 
the function of the bladder are readily restored as the temperature 
falls. Spontaneous action of the bowels is often easily accelerated by 
the use of an enema. 

The severe as contrasted with the mild cases of appendicitis are 
those in which pain requires repeated doses of an opiate for its relief, 
and in which the painful area increases at intervals of a few hours. 
There is but little fall in the morning temperature, and that of the 
evening is higher than on the previous day. Xeither gas nor faeces 
escape from the rectum, and there is often retention of urine, although 
there may be a frequent desire to empty the bladder. The abdominal 
distention rapidly increases, and the region of tenderness spreads in 
all directions, frequently into the pelvis. 

In these severer cases, which present the characteristics of a local- 
ized peritonitis, two possibilities are especially to be anticipated; the 
one is the circumscribing of the inflammation to the vicinity of the 
appendix, resulting in the formation of a sharply-defined, usually intra- 
peritoneal abscess, and the other is the generalizing of the peritonitis. 

Generalizing of the peritonitis sometimes takes place at the outset 
of the attack of appendicitis. The initial pain then is of extreme 
violence, and extends over the entire abdomen. There is often a severe 
chill ; the temperature usually is subnormal, but the pulse is rapid and 
feeble ; the abdomen is tense and retracted ; the skin is cool, moist, and 
at times mottled with livid spots ; the eyes often are sunken ; the face 
pinched; the voice husky. The patient may die during this stage of 
collapse, but not infrequently the patient rallies temporarily; the skin 
becomes hot, the abdomen distended, tympanitic, and fixed during 
respiration, and the pain and tenderness may diminish. Persistent 
vomiting is likely to occur, at times of a material resembling beef -juice, 
and death follows in the course of two or three days. These are the 
fulminating cases, which offer so little hope from any form of treat- 
ment. Without any considerable change in the course of the temper- 
ature as observed in the severe cases, the pain and tenderness rapidly 
and progressively spread from the starting-point, and require increas- 
ing doses of opiates for relief. The pulse gradually increases in fre- 
quency, and its force weakens. There is inability to take nourishment, 
and vomiting is frequent, and eventually fsecaloid. With progressive 



82 Inflammations of the Uterine Appendages and Peritoneum. 

loss of strength, the patient may be comparatively comfortable, but 
rarely survives beyond the first week; death not infrequently takes 
place suddenly and unexpectedly, often when the mental condition of 
the patient was so steadily improving as to make the outlook appear 
hopeful. 

Diagnosis. — A sudden attack of pain and tenderness in the right 
iliac fossa, associated with an elevation of temperature, however slight, 
in the great majority of cases is due to an attack of acute appendicitis. 
The evidence is strengthened if the symptoms are present in a 
young man. If the pain is intense, the tenderness exquisite, the abdo- 
men retracted, and the right rectus muscle rigid, it is probable that 
perforation of the appendix is present or imminent, and the appear- 
ance of a circumscribed resistance at the usual seat of the appendix, 
within twenty-four hours, strengthens this probability. The pain 
caused by disease of the appendix may be simulated by renal colic, 
whether due to the passage of concretions or to an acute hydronephrosis. 
Appendicitis is distinguished, however, from renal colic by the presence 
of fever, the gradual formation of a tumor, and the absence of hsema- 
tura. Attacks of biliary colic, due to the passage of gallstones, rarely 
simulate the pain from appendicitis, but pain, tenderness, tumor, and 
fever due to acute inflammation and distention of the gall bladder, may 
closely resemble the symptoms of appendicitis. The pyriform shape, 
superficial seat, and mobility of the tumor, and the frequently associated 
jaundice, are absent in appendicitis. An acute attack of pelvic peri- 
tonitis, especially of tubal or ovarian origin, may be mistaken for an 
attack of appendicitis. The tumor of intussusception is less tender, 
and the frequent tenesmus and bloody stools of this affection are lack- 
ing in appendicitis. In internal strangulation from intestinal obstruc- 
tion the symptoms are not sufficiently characteristic to eliminate 
appendicitis. The severity of the symptoms is such, in cases of doubt, 
as to demand medical treatment. 

Prognosis. — That appendicitis is frequently recovered from under 
medical treatment is a fact familiar to all physicians. 

According to Porter, in a collection of four hundred and forty- 
eight cases, the average mortality was about seventeen per cent. The 
death rate in ninety-five cases treated medically being nearly fourteen 
per cent, while of three hundred and fifty-nine acute cases operated 
upon, the mortality was about eighteen per cent, the average mortality 
of appendicitis may be stated as about fourteen per cent ; the important 
question relates to the prognosis of the individual case. All mild 
cases recover under medical treatment, and the risk of surgical treat- 
ment lessens with the mildness of the symptoms. The surgical opera- 
tion attended with the least mortality is that done after the patient 
has recovered from an acute attack. While the symptoms are those 
of a mild appendicitis, the individual prognosis is favorable ; but they 
may suddenly or rapidly change, and the outlook in severe appendicitis 
is always uncertain. 



Inflammations of the Uterine Appendages and Peritoneum. 83 

With symptoms of apparent severity in two patients, the one will 
die of general peritonitis, while the other quickly recovers. "The 
progress of the disease needs to be watched with a knife in hand." 

In mild cases of appendicitis the temperature usually falls by the 
third or fourth day, intestinal peristalsis is restored, pain and tender- 
ness disappear, and recovery takes place in the course of a week or ten 
days. In the severe cases death from general peritonitis is especially 
to be feared. The prognosis as to the individual depends, therefore, 
upon the presence or absence of the symptoms of an extension of the 
peritonitis, namely, rising pulse and temperature, and increasing dis- 
tention, with or without a tumor. The persistence of the temperature 
after the third or fourth day, and the presence of a sensitive tumor, 
even with a falling temperature, are indicative of a localized suppurative 
peritonitis, from which the pus may be absorbed, but following which, 
liability to recurring attacks is frequent. 

CHRONIC APPENDICITIS. 

In nearly one-half of the cases of acute appendicitis seen by 
Fitz there was more than one attack of the disease, separated by longer 
or shorter intervals of freedom from discomfort ; and from his expe- 
rience, therefore, the patient is as likely as not to have another attack. 
The recurrent has all the characteristics and possibilities of the original 
affection. The symptoms are the same, either mild or severe, and the 
prognosis does not materially differ, except that the more numerous the 
recurrences the less severe are they likely to be. If the intervals are 
long, perhaps months or years, each subsequent attack is regarded as 
a recurrent appendicitis. If the attacks are frequent, occurring at 
intervals of weeks or months, and in the meantime the patient is com- 
paratively free from uncomfortable sensations in the region of the 
appendix, the condition represents a chronic appendicitis, with a ten- 
dency to relapse, or simply a chronic or relapsing appendicitis. It is 
possible for a chronic appendicitis to exist without relapse, although 
these usually occur, and the lesions characteristic of a chronic appen- 
dicitis may be present as a result of an acute attack, and there be no 
symptoms indicative of this condition. 

"The disease chronic appendicitis, however, is to be recognized 
clinically by a series of symptoms localized in the region of the appendix. 
The essential feature in these symptoms is their persistence, intervals 
of relief being comparatively few. As Talamon has stated, chronic 
appendicitis is rather an infirmity than a malady menacing life, and 
he has given the term "appendicular colic" to the frequent attacks of 
temporary pain in the region of the appendix. 

"The patient is in a condition of more or less pronounced invalidism. 
Severe or trivial disturbances of digestion produce pain and sensitive- 
ness in the region of the appendix, compelling the patient to remain 
quiet for a day or two. With the pain and tenderness there may be a 



84 Inflammations of the Uterine Appendages and Peritoneum. 

slight elevation of temperature. Sometimes constipation is associated 
with or precedes the discomfort, and occasionally a dull, resistant mass 
of considerable size is to be felt in the region of the caecum, due to the 
retention of fsecal matter. This combination of retained faeces, and 
a painful and tender appendix, is the stereocal-typhlitis of the old 
writers, and is evidently the result of a mild attack of appendicitis, 
associated with constipation. In such cases relief often follows evac- 
uation of the bowels, perhaps from the removal of a mechanical obstruc- 
tion at the mouth of the appendix. On official examination of the 
right iliac fossa in the interval between the attacks of pain, the enlarged 
appendix is often to be felt as a distinct tumor, perhaps of the size of 
the little finger, either directly beneath the abdominal wall or deep 
seated in the iliac fossa. At such times there may be even tenderness 
on palpation, and the patient is usually conscious of localized resist- 
ance offered. The more frequent the recurrence of the symptoms, and 
the shorter the interval between them, the more enfeebled the patient 
becomes. The patient is not infrequently prevented from continuous 
work; he is debarred from the pleasure and profits of travel, through 
fear of an attack of pain and its possibilities while at a distance from 
competent medical or surgical treatment. In addition to the constant 
uncertainty as to freedom from discomfort, there is always danger of 
the occurrence of an acute attack of inflammation, resulting in perfora- 
tion. The patient is often irritable and nervous, and becomes self- 
centered and timid. Pepper has characterized this condition as one 
of the most troublesome of curable affections. The symptoms may 
be protracted over a period of years, and we are indebted to Treves for 
advocating the removal of the appendix when the patient has recovered 
from an acute attack. Cases of chronic appendicitis sometimes closely 
simulate those of cancer of the caecum, for there is a condition of pro- 
gressive loss of flesh and strength, failure of appetite, weakness of diges- 
tion, irregular action of the bowels, sometimes mucous discharges, and 
a resistant tumor, not especially tender, in the region of the caecum. 
To eliminate this possible error in diagnosis, importance is to be attached 
to an accurate history of the beginning of the attack, and to the fre- 
quent observations of the temperature. In such cases the diagnosis 
may first be made by means of an exploratory laparotomy. The prog- 
nosis of chronic appendicitis, though in general favorable as to life, 
is always uncertain. 

"Treatment. — The treatment of the individual case of appendicitis 
is almost always surrounded with great anxiety, on account of the dif- 
ficulty, in fact, in many cases the impossibility, of determining in the 
outset of a case whether it should be looked upon as one of fecal accumu- 
lation in the caecum, with associated inflammation of the appendix, or 
as one of mild catarrhal appendicitis, or whether ulceration or perfora- 
tion exists. 

"The methods of treatment which have their advocates are not only 



I)i flammed ions of the Uterine Appendages and Peritoneum. 85 

various, but antagonistic, at least so far as the giving of drugs is con- 
cerned. All are in accord in inculcating absolute quiet in bed, with 
total abstinence at first from food other than chicken or other broths, 
without rice or similar material in them, followed, when the time comes, 
by the addition of raw eggs, or other albuminous liquid food, pure milk 
being avoided on account of the tendency which it has to produce curds, 
although when diluted with carbonic acid water it is sometimes agree- 
able and useful. 

"The points in regard to which there are great differences of opin- 
ion are, first, as to N the use of local measures ; second, as to the use of 
opium ; third, as to the employment of calomel, and of saline or other 
purgatives, and as to operative procedures. 

"Local applications consist in the use of heat and cold, of leeches, 
and of blisters. So far as concerns the use of heat or cold, I believe that 
the sensations of the patient are the safest guide. If the continuous 
application of the hot-water bag gives the greatest comfort, it should 
be preferred ; if the application of ice reduces the pain and is agreeable 
to the patient, it should be selected. Except in rare cases, the only 
objection that can be urged against the proper use of leeches is the triv- 
ial influence the leech-bites may have on any surgical procedure that 
afterwards becomes necessary. I do not believe that this objection has 
much force; it requires only a little more care thoroughly to disinfect 
the leech-bites than surgically to cleanse the sound skin. The effect 
of the leeches upon the disease varies with the character and the cause 
of the attack. If the attack is the outcome of ulceration or gangrene 
of the appendix, or if the appendix is the center of an active infective 
process, leeches have no influence upon the local inflammation; on the 
other hand, if the inflammatory action is the outcome of a typhlitis- 
stercoralis, and is of slow development and of comparatively little force, 
leeches may be very useful, especially in gaining time for the employ- 
ment of salines. Blisters I do not believe to be of any value in acute 
appendicitis. The blistering increases the suffering of the patient, and 
has little or no effect upon the spread of the inflammation ; it also inter- 
feres with the work of the surgeon. 

The use of opium is an exceedingly important one, concerning 
which there has been much discussion, which, so far as I am concerned, 
has led to some alteration of views. I still believe that opium does 
good in these cases, by controlling pain and restlessness, and it also acts 
anti-phlogistically in some unknown way. On the other hand, there 
is great force in the surgical contention that opium interferes with 
intestinal secretion and peristalsis, and especially to mask the symptoms 
or to greatly enhance the difficulties of deciding the progress of the 
case and the time at which surgical interference should be adopted. I 
believe, therefore, that unless opium is called for by the presence of 
excessive pain, it is best to avoid its use, and that, when used, it should 
be given in the form of hypodermic injections of morphine. 



86 Inflammations of the Uterine Appendages and Peritoneum. 

"The difficulty surrounding the question of the administration of 
salines is largely one of diagnosis. If the appendicitis is connected 
with faecal accumulations in the caecum, the administration of salines 
until the bowels have been thoroughly emptied is strongly indicated. 
If on the first day of a mild appendicitis there is the sense of the pres- 
ence of a tumor imparted to the fingers on palpation, salines should 
always be given, and in many cases their use should be combined with 
that of calomel. It is better to give repeated small doses than a single 
large dose, the large dose being much more apt to cause vomiting than a 
small one, also to cause distress. Magnesium citrate is probably the 
best of salines, on account of the pleasantness of its taste ; sodium sul- 
phate is more certain in its action; its bitterness, however, makes it 
more nauseating, though lemon juice with a little sugar added covers 
the bitterness of the salts. 

"It is a significant fact that, while formerly scientific physicians 
utterly abandoned and condemned the use of calomel in such diseases 
as diphtheria, it was largely used by country practitioners, and through 
their influence has been forced back upon the leading members of the 
profession. The same class of practitioners have often affirmed to me 
that they have seen an appendicitis improve simultaneously with the 
coming of ptyalism. I regard their evidence of practical value. In 
the class of cases of appendicitis now under consideration, when there 
are no perforations, and no gangrene or hopeless septic infection, in my 
opinion calomel should be administered. It acts as a laxative, and also, 
according to my belief, as an anti-phlogistic remedy. 

"At alternate half hours the patient may take an ounce to an ounce 
and a half of magnesium-citrate solution, and a half grain of calomel, 
the calomel being dropped when from seven to ten grains have been 
taken, even if no action of the bowels has occurred, and the saline being 
' administered hourly, day and night, until a free passage has been 
obtained, or until the impossibility of doing so has been demonstrated. 

"When ulceration, perforation, or gangrene is present in an appen- 
dicitis, the saline can do no good, and may readily do harm, so that they 
should not be exhibited. It is, however, impossible in most cases to 
determine positively when perforation or ulceration occurs, so that it 
may be considered as a rule of practise to use the saline in the begin- 
ning of an appendicitis which is not explosive in its type. If, however, 
the practitioner should believe that there is probably ulceration or gan- 
grene of the appendix, the purgative should be used only if absolutely 
necessary to overcome demonstrable faecal retention. The opinion of 
many of the best of our surgeons that the presence of faeces in the colon 
greatly increases the danger of the operation upon the appendix, can 
not properly be disregarded. In almost all cases of appendicitis 
enemata are valuable ; if there is reason to suspect that there is ulcera- 
tion or perforation, they alone must be depended upon to clean out the 
colon ; if these complications are absent, they may be used to assist the 
saline laxatives. 



Inflammations of the Uterine Appendages and Peritoneum. 87 

"The most vital problem in any case of appendicitis is as to the 
propriety of surgical interference. Kesolution after ulceration and 
formation of an abscess is such a rarity that the possibility of its occur- 
ring in any case should not be taken into consideration. When, there- 
fore, there is reason to believe during an acute appendicitis that perfora- 
tion or the local formation of pus has occurred, or that the appendix 
has become gangrenous, immediate operation should be performed. On 
the other hand, very frequently, perhaps in the great majority of cases, 
it is impossible to diagnose accurately the condition of the appendix; 
so that the question naturally presents itself as to what would be the 
result of operating upon every case, as contrasted with the results of 
using the expectant treatment, with selection of cases for the surgeon. 
There are, however, no sufficient statistics to warrant definite conclu- 
sions on these points. The opinion put forth by some surgeons, that 
the operation is free from danger, is, in my opinion, erroneous. The 
question of the skill of the operator is in appendicitis a most important 
one. The operation should be undertaken with the greatest sense of 
responsibility, and only by those who by previous training are thor- 
oughly prepared. It should be carried out with the most absolute 
asepsis. It being understood that a proper surgeon is available, the 
following rules seem the best that can be laid down for guidance in this 
matter : — 

"First, when the onset of the attack of pain, the tenderness, and the 
tympany are excessive, and the fever and pulse rapidly rising, the 
probabilities of an acute perforating appendicitis are such that an 
immediate operation should be performed; each hour lost sensibly 
increases the danger. 

"Second, when, in a case of mild appendicitis, sixty hours of care- 
ful treatment have gone by without any distinct abatement of the symp- 
toms, the operation should usually be performed, except in the rare 
cases in which masses apparently fsecal in character have been detected 
at the beginning of the attack in the head of the colon, away from the 
immediate neighborhood of the appendix. 

"Third, an immediate operation should be performed when in 
hitherto mild cases a sudden increase in the local and general symptoms 
points towards the occurrence of perforation or the formation of pus, 
this rule being imperative if the acute symptoms are accompanied by 
such widespread general tenderness and marked increase in the fever 
and pulse rate as to indicate the coming on of a general peritonitis. 
In such cases minutes are important ; and unless the operation can be 
performed before the full development of septic peritonitis, the result 
will almost certainly be death. 

"During convalescence from appendicitis great caution should be 
exercised in getting the patient back to ordinary food, and laxatives 
must be used freely if needed. Even after recovery care should be 
taken to avoid indigestible food, fruits containing seeds, violent exercise, 



88 Inflammations of the Uterine Appendages and Peritoneum. 

or any exertion which will throw strain upon the abdominal muscles, 
and which might, by breaking up an adhesion, stir up a slumbering 
inflammation. The bowels shoiild be kept perfectly soluble; if there 
be a remaining induration, persistent mild counter irritation, especially 
with iodized oil, may be used locally. No drugs except laxatives are 
of any avail. 

"Recurrent appendicitis often gets well finally without an opera- 
tion, but certainly very grave risks attend leaving the case to nature. 

"At the operation the appendix should be taken out, provided it 
can be done without too much injury, or without such manipulations 
as^may rupture posible adhesions, or bring about the escape of septic 
matter into the peritoneum. The question of removal or non-removal 
must be settled during the operation by the surgeon." 

The writer will add to the subject of appendicitis a short article, 
following the above subject, which is most excellent common-sense 
advice to all mothers. The initials of the author are R. H. F. : — 

"Recognizing the impossibility of satisfactorily determining at the 
outset how an attack of appendicitis is to end, but convinced that the 
large majority of cases recover quickly, easily, and with safety under 
medical treatment, it seems to me advisable to advocate such treatment 
as shall favor the predominant tendency of this disease to terminate 
in resolution. 

"From this point of view the essentials are to check peristalsis above 
the caecum and to relieve the pain. Repeated instances have occurred 
of the aggravation of the symptoms soon after the administration of 
laxatives by the mouth, often by an anxious mother, who attributes the 
abdominal pain to the presence in the intestines of indigestible food 
or retained faeces. All cathartics are, therefore, to be avoided until 
convalescence is established, and only the blandest liquid diet is to be 
permitted. 

"If constipation has preceded the attack, or the colon is distended 
with gas, a rectal enema often gives relief, and does not threaten the 
tearing apart of delicate tissues or adhesion, whose influence is pro- 
tective, or risk the perforation of a weakened appendix. 

"The relief of pain is best accomplished locally by means of hot 
or cold applications. If these are ineffectual, morphine should be 
given, beneath the skin, by the mouth, or in a suppository by the 
rectum, in such quantities as to keep the patient comfortable. Small 
doses are usually sufficient for this purpose. 

"If resolution is to occur, it is likely to take place by the third or 
fourth day ; hence, when the condition of the patient permits, an oper- 
ation should be delayed until this time. The surgical treatment of the 
acute attack is always to be avoided when possible, because it is unnec- 
essary in the majority of cases, and is followed by the subsequent risk 
of a hernia. If eventually required, it is more safely employed in the 
absence of acute inflammatory symptoms, and there is afterwards less 
likelihood of hernia. 



Inflammations of the Uterine Appendages and Peritoneum. 89 

"The removal of the appendix for chronic inflammation is to be 
recommended in those cases in which recurrences are frequent, or the 
tendency to relapse is such as to produce a state of semi-invalidism." 

Returning now to the inflammatory condition of the female gen- 
ital organs, we remark that when an appendicitis develops in conjunction 
with an enlarged uterus, confusion is sometimes unavoidable, as phys- 
ical examination may show a close connection between such a uterus 
and the inflamed area. But a careful study of symptoms will suffice 
to establish the intestinal, rather than the uterine, origin of the ailment. 

If inflammation within the area of the true pelvis be due to the 
appendages, an antecedent history of uterine disease will always be 
present ; there will be a constant relation between the exacerbations 
and the uterine symptoms. If the lesion be due to the abnormally- 
placed appendix, let it be noted that, while the latter may stretch across 
the entire pelvis, yet it very rarely does so, resting completely upon the 
right side, near the attachment of the broad ligament to the pelvic wall. 
The diseased organ would then be nearly always upon the same side, 
where it is to be distinguished from an inflammation of the right 
appendages. If the mass be small, palpation may enable one to detect 
the free tube and ovary ; but if it be large, it may implicate these struc- 
tures, and may encroach upon the uterus. Under such circumstances 
it is very difficult to arrive at a diagnosis from the physical signs, unless 
the thickened appendix can be traced across the pelvic brim to the con- 
nection with the csecum in the depths of the iliac fossa. We often have 
to depend upon symptoms ; much can be made out of the fact that the 
acute symptoms, and those belonging to the exacerbations of appen- 
dicitis, are more explosive than those associated with inflammation of 
the appendages ; and they are commonly more severe, both in their local 
and in their general expressions. Aspiration is an aid to diagnosis 
after suppuration occurs. Should frecal matter be obtained, it would 
be conclusive as to the presence of appendicitis; but pus with simply 
a faecal odor would not be conclusive, as any purulent collection near 
a large intestine may possess this odor. 

Referring now to the differentiation of the organs which are 
involved in the pelvic inflammation of the uterus and appendages, we 
find that in the milder grades of the affection this is comparatively 
easy, especially if one resorts to recto-abdominal palpation. The out- 
line of the thickened tubes can be followed from the cornu of the uterus 
to its bulbous or cystic enlargement at the inf undibula ; its convolutions 
may be recognized. The outline of the ovary may be felt, encircled, as 
it is apt to be, by the enlarged tube. A mere enlargement of the ovary 
may likewise be distinguished from that of the tube, the latter being 
traced to its connection at the cornu, and found free from abnormal 
thickening. The uterus under such conditions is so free that, no mat- 
ter what may be its position, its outlines can always be made out. 

The distinct evidence of cellulitis consists in the development of a 



90 Inflammations of the Uterine Appendages and Peritoneum, 

mass within the upper folds of the broad ligament, in connection with 
abortion or labor, when by rectal palpation one is able to distinguish 
free ovaries and tubes. Extreme cases of pelvic inflammation rarely 
permit recognition of separate organs. There is such an amount of 
peritoneal exudate that, beyond the uterus, the outlines of individual 
structures are hopelessly lost; even the outlines of the uterus may be 
lost, but the sound will always locate this organ, from which, as a start- 
ing-point, we gain information as to the relative implication of the two 
sides. 

The differentiation of pyosalpinx, hematocele, and hydrosalpinx 
will be aided by the copious and sudden discharge from the uterus of the 
fluid characteristic of each ; but if this fails, and a diagnosis is deemed 
essential, the aspirator may be used. A small ovarian tumor might be 
complicated with hydrosalpinx; but the latter condition would always 
present the antecedent history of chronic pelvic inflammation. Should 
the ovarian cyst develop subsequently to the tubal disease, careful pal- 
pation might enable one to distinguish the tube, and then by ascertain- 
ing its condition, to determine the question. 

Pelvic abscess is recognized by the appearance of the fever of 
suppuration, by a slight aggravation of the severity of the local symp- 
toms, by increase in the size of the mass, and by fluctuation. Pus is 
detected by the aspirator. Whenever the aspirator is employed, the 
rule is to empty, so far as possible, any sac into which the needle is 
introduced, because if this is not done, and the sac is left tense with 
fluid, there may be escape through the opening made by the needle, and 
this might cause serious trouble. 

Prognosis.- — According to various writers upon this subject, the 
prognosis is that the milder forms of salpingitis and ovaritis, etc., tend 
to recovery. Whenever the thickenings remain, and fixation shows the 
persistence of adhesions, the disease remains. The persistence of 
symptoms likewise shows an unfavorable condition of affairs. The 
prognosis in all such cases is unfavorable from the standpoint of 
health and functions, but treatment may modify this prognosis, so as 
at least to improve health, if it does not restore the function. The 
appearance of peritonitis is always a grave indication, and the more 
acute and widespread the evidence of this condition becomes, the graver 
the prognosis. The same statement applies to sepsis. Whenever either 
of these conditions is widespread, death usually occurs, closing the 
scene. 

The acute pelvic inflammation associated with the recently pregnant 
uterus, is the most serious form of inflammation. The septic inflam- 
mation of the non-pregnant uterus is the next in point of gravity ; then 
come those dependent upon gonorrhea. 

When the disease passes into the chronic form, the periods are 
those covered by the acute exacerbations. Any of these accessions may 
lead to a general peritonitis or to an abscess. Whenever an abscess 



Inflammations of the Uterine Appendages and Peritoneum. 91 

appears, the patient is exposed to the dangers of a possible rupture 
towards the free pertitoneal cavity, on the one hand, and those pertain- 
ing to long suppuration, on the other. 

Whenever there are extensive adhesions, and these appear to be 
organized, the prognosis as regards recovery is very bad, but not so as 
regards life. 

Patients may pass a fairly comfortable life, but the greater number 
of them are chronic sufferers. The influence of prolonged suffering is 
in itself a grave factor upon some constitutions ; so that, although the 
patient may live, yet she lives at such a cost as to rob existence of much 
of its value. Then, too, the undermining which her constitution inev- 
itably undergoes, makes her an easy prey to intercurrent disorders. 
The mild acute forms of pelvic inflammation tend to recovery; the 
graver forms tend to become chronic, to terminate in pelvic abscess, 
and are sometimes rapidly fatal. The chronic forms tend rather to 
life-long chronic invalidism. 

Pelvic abscess is always a grave affection, because of the possibility 
of infection of the general peritoneal cavity, and because of the possi- 
bility of prolonged suppuration and sepsis. 

It is said that sterility usually is one of the phases of this ailment, 
but it is not always so. It is also said, — a matter which should not 
be overlooked, — that it relates to the possibility of extra-uterine preg- 
nancy. The constrictions and other deformities produced in the tubes 
by inflammation appear to obstruct the passages of the fecundated ovum, 
so that an extra-uterine development may occur. This condition must 
therefore be taken into consideration in any prognosis that may be given. 

The prognosis may, however, be favorably modified by the proper 
treatment, which we are now coming to. 

Treatment of Pelvic Inflammation. — We will give only medicinal 
treatment, and refer to such cases as will come under the head of oper- 
ative procedures, which belong to gynaecological surgery. In the gen- 
eral treatment we will endeavor to advise our sex as to the importance 
of following the physician's advice in all cases of this ailment, as it is 
a disease that is liable to relapses, through any imprudence, and the 
patient is liable to pass into chronic invalidism, if death does not close 
the scene. 

Acute pelvic inflammation requires, in the milder types of this 
infection, little beyond rest in bed, gentle saline catharsis, hot douches, 
and hot poultices over the hypogastric region. In some cases the hot 
poultices will have to be applied all over the abdominal region in the 
beginning of the onset of the affection, and a hot-water bag filled about 
one-third full may be laid over the poultice, over the hypogastric region. 
The poultice may be changed every six or eight hours, which is often 
enough, provided the hot-water bag is kept hot over the hypogastric 
region. If there is no hot-water bag at hand, the poultice should be 
frequently changed for fresh hot ones, both day and night, until relief 
from pain is secured ; then the poultices may be discontinued. Bathe 



92 Inflammations of the Uterine Appendages and Peritoneum. 

all over the hypogastric and abdominal regions with liniment of spirits 
of turpentine and spirits of camphor, equal parts; then apply cotton 
batting over the affected region, and a hot-water bag on the batting over 
the hypogastric region. This part of the treatment should be kept up 
until the patient is well out of danger ; and should the pain return, the 
hot linseed poultice will have to be applied again, as in the beginning. 
Gentle saline catharsis, such as citrate of magnesia, or Epsom and Roch- 
elle salts, equal parts, should be given in small doses every one or two 
hours, until the bowels are gently moved. It is a good plan to give one- 
fourth to one-sixth of a grain of calomel, an hour apart, until four doses 
are^ taken; then wait six hours after the last dose of calomel has been 
taken, and give a dose of Rochelle and Epsom salts, equal parts, about 
a heaping teaspoonful of each, in a half tumblerful of warm water, to 
move off the calomel; if this does not move the bowels in four or five 
hours, another dose of the salts should be repeated, or an enema of warm 
water, about one pint with a teaspoonful of table salt added to it, is 
usually sufficient to move the bowels. Hot vaginal douches should be 
given every six or eight hours, both night and day ; the temperature of 
the water should be 110 degrees to 115 degrees Eahr. If there is no 
thermometer at hand, have the water as hot as can be borne on the back 
of the hand, using care that the patient is not exposed to the air while 
the douche is being given, and avoid undue exertion in placing the bed- 
pan in position for the douche. If there is much pain, or if there are 
such shocks as belong to the acute suppression of menstruation, then 
opium should be given, either by the mouth, or hypodermically, or in a 
suppository by the rectum, about the same as that already prescribed for 
the milder forms of acute metritis. As soon as the acute symptoms sub- 
side, vaginal tamponade, as already described, should be used, provided 
the pressure does not cause pain; and in that case the ichthyole and 
glycerine tampon must be omitted until it can be used without discom- 
fort. 

Absolute confinement to the bed is imperative so long as the acute 
symptoms prevail. A nurse is needed to give the proper attention to 
the emptying of the bowels and bladder, which must be done in the 
recumbent posture. The bladder is often emptied spontaneously while 
the hot vaginal douches are given ; it is a good plan to remind the patient 
to try to void the bladder while the douche is being given. Free saline 
catharsis is at first very beneficial ; after that a daily movement of the 
bowels with citrate of magnesia suffices. 

If the case be septic or gonorrheal, the interior of the uterus should 
be treated, if this has been omitted. The mischief which an early 
treatment of the uterine cavity would have prevented is present here ; 
but free the uterus of debris, and then provide drainage, by means of 
the gauze, as already described in the treatment of endometritis and 
metritis, keeping constantly before the eye the probability of the devel- 
opment of peritonitis and sepsis, for these are the conditions that call 



Inflammations of the Uterine Appendages and Peritoneum. 93 

for operative measures. Sepsis goes hand in hand with peritonitis as 
much as it does with appendicitis. a Unfortunately the seat of sepsis 
is in one instance an organ of small moment, with no connection; 
whereas, in the other, its seat is in the uterus, an organ of such wide- 
spread and intricate anatomical connection that it can not be dealt with 
in the prompt and radical fashion found so serviceable in cases of the 
appendix. This being the fact, it remains a problem as to how far 
surgical interference should be carried in the condition before us. The 
more general the implication, the more hopeless is surgical interference. 
Therefore, the moment that symptoms and signs appear which indicate 
the coming of general peritonitis, or the advent of sepsis, operation 
should be done." 

The most radical procedure permissible is the removal of the 
appendages; but should the state of the patient forbid this operation, 
or the firm fixation of the appendages involve too much shock in their 
removal, then one must be content with a free opening into the center 
and depth of the inflamed mass, and subsequent drainage. This part 
of the treatment of pelvic inflammation is left to gynaecological sur- 
gery, which is a specialty. However, if the patient will not submit 
to an operation, it remains only to support the power of the patient by 
food and stimulation, and to ease the pain by opium, hot fomenta- 
tions, or linseed poultices. Daily catharsis with magnesia citrate, 
and an occasional dose of one-fourth of a grain of calomel whenever 
there is a brown coat on the back of the tongue, will add to the comfort 
of the patient. From time to time throughout the disease the patient 
may be rubbed with warm alcohol ; and if there is very free sweating, 
the patient may be sponged with hot soda water. Put about a table- 
spoonful of bicarbonate of soda, or baking soda, into one gallon of hot 
water, sponge the patient under a blanket, and dry with warm towel; 
then rub with warm alcohol. Before commencing to give the bath, 
I have found it a good plan to give the patient a tablespoonful of good 
whisky, to prevent a chilly sensation occurring while the bath is being 
administered. 

At times during the course of this disease perspiration becomes 
profuse, and a small dose of atropine, 1-200 of a grain, will correct 
this condition; and if there is pain, the morphine and atropine may 
be given by hypodermic injection. I will also add that the patient 
should not be allowed any company until convalescence is established. 

We come now to the treatment of chronic pelvic inflammation, 
which varies with its duration. In the early stage of chronic pelvic 
inflammation, if the uterus especially be in the early stage of endo- 
metritis and metritis, this organ must receive the same treatment as 
that prescribed under the head of chronic endometritis and metritis, 
which is curetting and packing the uterus with sterilized gauze, as we 
have already explained. This will, in the majority of cases, cause a 
speedy improvement towards restoration to efficient health. The vagi- 



94 Inflammations of the Uterine Appendages and Peritoneum. 

nal tampon may be used, at intervals of two days, for a month or more. 
A hot vaginal douche given at bedtime is very beneficial. 

If a case of chronic pelvic inflammation is of long standing, and 
if the uterus is in a state of induration, such as belongs to the latter 
stages of chronic metritis, the galvano-uterine raclage, given according 
to Apostolus method, will aid in relieving the induration and softening 
up the adhesions, and if persevered in will save many women from hav- 
ing to have the appendages removed. The writer believes that, too, 
many young women are allowing their ovaries to be removed when by 
patient electro-galvanic treatment the ovaries could be saved. If the 
ovary contains pus, it and the associated tube should be removed. If 
the tube only contains pus, and the ovary is free from pus, the operator 
is at liberty to amputate the tube and leave »the ovary. The same rule 
applies in cases of hydrosalpinx and hsematosalpinx. 

Cysts of the ovary can be enucleated, leaving the ovary. Adhe- 
sions do not demand the removal of the tubes and ovaries. 

In all cases of sub-acute or chronic tubal disease, it is of the first 
importance to treat the interior of the uterus. Curetting it with a not 
too sharp curette, and then firmly packing it with sterilized gauze, is 
the best method to begin with; after two or three days remove the 
gauze from the uterus, and give hot douche, and then apply a tampon 
made of absorbent cotton or wool, dipped in ichthyol and glycerine, 
packing it well up around the uterus. The tampon may be removed 
on the second evening at bedtime, and the hot douche applied, and on 
the third morning another hot douche and a tampon; this treatment 
is thus kept up until the patient is able to recline on a couch, when the 
galvanic current of electricity should be applied, care being taken not 
to expose the patient unduly while the current is being given. We will 
, add that usually at the end of a month after the curetting, etc., the 
patient should begin taking the galvanic current of electricity to aid in 
the absorption of the adhesion of the uterus and its appendages. 

We will give in detail the method and certain rules governing the 
seances of galvano-electricity, which the writer has applied satisfactorily 
in her own work in this field. 

Apostoli, of Paris, to whom must be awarded the credit of having 
developed this departure in therapeutics, Was fortunately in a position 
to demonstrate his procedure, and to hold his cases before the profes- 
sional eye, so that skeptics could believe, and seekers after truth could 
profit, by his teaching, and put into practise for themselves the various 
expedients which he had devised. Thus it was not long before physi- 
cians of note, anxious to seize upon whatever help could be secured for 
the alleviation of woman's suffering, and a more perfect restoration to 
health than had hitherto been possible, took the matter up, and have 
since persevered in its study. The time which has elapsed since its 
inception, and the continued interest which still attaches to it, demon- 
strate more fully than could any words of praise in what general esteem 



Inflammations of the Uterine Appendages and Peritoneum. 95 

this method of treatment is held. The study is full of interest, and 
it is to be hoped the practise maj eventually be estimated at its true 
value, and that those who are unwilling to depart from "well-beaten 
paths' 7 will be brought to accept proven truths and demonstrable facts ; 
for it is inevitable that every new method should have its strong advo- 
cates and its detractors. It is not to be expected that gynaecologists 
developed in the infancy of the art, say even twenty years ago, will turn 
their attention with much seriousness to a new idea of this kind, cer- 
tainly not to the extent of busying themselves about the details of its 
correct application ; nor is it even to be expected that they will relin- 
quish their old methods, even though they require months to accomplish 
what a few weeks will do nowadays. 

I am not one of those who believe this treatment can be applied 
only by physicians who have made it their study for years. It will not 
be doubted that those of us who have been anxious to test this method 
of treatment have fully informed ourselves as to the nature of the rem- 
edy, its intended mode of action, and its application. Notwithstanding 
the importance of being familiar with quality, resistance, amperage, and 
the minutiae of this subject, we may still reduce the practical application 
of galvanism to a few simple rules, viz., have a sufficiently powerful 
battery, be able to measure the force of the current, be familiar with 
the action of the two poles, be sure of the condition to be treated, have 
a correct understanding of the results to be obtained, and a just appre- 
ciation of the effects produced ; further than this, a judicious selection 
of the appropriate case to be subjected to such treatment, and the proper 
choice of instruments and mode of application, will, I think, render 
a man or a woman competent to solve for themselves some of the ques- 
tions involved, and to have an intelligent understanding of its merits 
and its shortcomings. 

One prevailing objection of many physicians is the inconvenience 
connected with the adoption of this mode of treatment. It requires 
considerable time to get all the appliances in readiness for work; it 
requires special care for the patient to guard against infection; and 
it demands the physician's close attention in applying it. The phy- 
sician may meet with some disappointments by undertaking too much, 
or may not do a little very well, and consequently may not get good 
results. Another disagreeable element is that patients will often dis- 
continue treatment as soon as they feel improved in their general 
condition of health, regardless of the fact that such relief may be the 
first step in the process of cure. As a matter of fact, however, almost 
all patients feel considerable general improvement after treatment with 
electricity, which is undoubtedly in large part due to general stimulation. 
The nutrition of the body at large is greatly improved. This stimulus 
apparently does not result in the improvement of the nerve tone alone, 
thus producing the more rapid and regular evolution of nutritive pro- 
cesses, but seems to affect the blood and tissues themselves, causing a 
chemical change in their elements. 



96 Inflammations of the Uterine Appendages and Peritoneum. 

Some of the pelvic affections in which I have used electricity, either 
as a destructive or as a constructive agent, to arrest growth, to pro- 
mote absorption, to relieve pain, to arrest hemorrhage, many times as 
an adjunct to other methods of treatment, are amenorrhea, stenosis, 
causing sterility, dysmenorrhea, menorrhagia and sub-involution, 
passive engorgement of the uterus (flabby uterus), endometritis, mem- 
branous-dysmenorrhea, catarrhal-salpingitis, oophoritis, parametritis 
and perimetritis (plastic exudations), fibroids, and malignant diseases 
of the cervix, such as cancer, ulceration of the cervix, and tuberculosis 
of the uterus. 

* The most definite and well-proven points regarding the polar action 
of a continuous current are that the positive is acid, sedative, and haemo- 
static. The negative pole is alkaline, producing a hyper-sensitive con- 
dition, and increasing bleeding. Each is diametrically opposed to 
the other. Physicians just beginning the use of electricity will do well 
to keep these points in view, as success is largely dependent upon which 
is used for the active pole. 

In 1859 Funke discovered that a sound nerve is neutral or feebly 
alkaline, but changed to acid on coagulation setting in or on exhaust- 
ing it by prolonged mechanical or electrical stimulation. The death 
of the muscle is marked by a progressive acidity, and subsequent coag- 
ulation of muscular plasma. The same is true also of nerve substance 
as well. Then, if it is true that the death of the muscle or nerve com- 
mences when an acid condition sets in, it is also true that an inflamed 
or overactive condition is due to excessive alkalinity. These points 
have been proven, hence we insert them here without apology or expla- 
nation. 

All inflammations are primarily local, due, as stated above, to 
excessive alkalinity of the part ; not, as it is said, that the system con- 
tains an excess of alkali, but that we have an unequal distribution of 
probable normal alkalinity. 

We quote from such excellent authority as Dr. J. Mount Bleyer, 
who says, "Yet all this points to one conclusion and one deduction, that 
animal electricity comes first ; that it is the prime factor in all processes 
of change, of chemical action, or otherwise, within the living body; 
that without its stimulus of polarization no chemical action can be 
called into life ; consequently none can go on, and tissue metamorphosis, 
which is life itself, must cease." 

Why is it, then, when we place the positive pole over an inflamed 
and painful surface, that the inflammation and pain subside ? Oxygen 
is set free at the positive pole. Oxygen, we are taught, is an acid-maker, 
and the part in contact with the pole being changed to a condition of 
activity, the temporary death of the part has commenced, or is in a 
state of sedation, evinced by a circumscribed anaesthesia. But what 
has become of the alkalinity that existed previous to the application 
of the positive pole ? It certainly has not been neutralized by the acid- 



Inflammations of the Uterine Appendages and Peritoneum. 97 

ity of that pole, because that would necessitate an evolution of gas, 
which has not taken place. As it is said, alkalies are electro-positive 
substances, and have an affinity for the negative pole. Consequently 
the excess of alkali at the point of inflammation is transferred to the 
neighborhood of the negative pole, which immediately assumes a hyper- 
sensitive condition, proving that excessive alkalinity causes inflamma- 
tion, because the part was perfectly normal before the application of 
the negative pole. Hence, according to the above theory, the positive 
pole, placed over the adhesions, is the one to promote the degeneration 
of adhesions, masses, and all enlargements, wherever situated. The 
one ideal object is to place the positive pole as nearly in contact with 
these as possible to bring about the desired effect. This thought is ever 
prominent in my mind when dealing with electro-therapeutical meas- 
ures for the absorption of such lesions. 

A trustworthy galvanic battery and a good milliamperes meter and 
a rheostat are most important for the success of these special measures 
adopted for the absorption of all adhesions, masses, growths, and con- 
gested conditions of the uterus and its appendages. 

In all cases the electrician should use judgment in stimulating the 
generative organs to a proper degree to overcome suppressed or defective 
menstruation. 



CHAPTEE V. 
DISPLACEMENTS OF THE UTEKITS. 

Definition. — By displacement of the uterus is implied a more 
or less permanent deviation of that organ from the position which it 
naturally holds in perfect health. 

x - Under normal conditions, the uterus occupies a position between 
the bladder in front and the rectum behind, the general abdominal 
cavity above and the vagina below. 

The uterus is composed of body and neck, or, in the Latin terms, 
corpus and cervix. The body of the uterus comprises two-thirds of 
the bulk of the whole organ; the neck or cervix composes the remain- 
ing third. The upper portion of the uterine body is known as the 
fundus, and is situated above the exit of the Fallopian tubes and round 




Fig. 2. — Uterus and Appendages, Front View (Beigels). 



ligaments. The uterus receives its support from the utero-sacral 
ligaments behind, the broad ligaments on either side, the round liga- 
ments in front, and from the connective tissue of the pelvis. As 
the peritoneum dips down between the organs and over the Fallopian 
tubes, it includes a certain amount of the cellular, or connective, tis- 
sue between its folds, which, with a few muscular fibers, form the 
uterine ligaments. These ligaments, with the exception of those 
from the uterus to the sacrum, offer but little resistance to any down- 
ward presure or prolapse, and serve only as guys to steady the organ 

(98 



Displacements of the Uterus. 



99 



and to oppose a tendency to version. They are aided in this by the 
folds of the vagina about the cervi, and by the cervix, which acts as 
a pivot or lever to maintain the axis of the uterine canal in its natural 
relaxation to the vaginal axis. The length of the normal uterus, as 
measured by a sound passed into the cavity, is two and a half inches. 
In shape, the uterus resembles a pear. The slenderest part of the 
uterus is the point at which the cervix joins the body, and it is at 
this point that flexions of the organ most frequently occur. 

Normal Position of the Uterus. — There is a diversity of opinion 
among authorities as to the normal position of the uterus. It is 
impossible to establish a point which can be accepted as its normal 
position in health. This difficulty arises from the fact that each 
woman has her own individual point, from which, however, some 
deviations frequently occur without being necessarily the result of 




Fig. 3. — Uterus and Appendages, Rear View (Beigels). 

disease. The uterus will change, its position in health with every 
movement of the diaphragm; it will also be influenced by the condi- 
tion of the bladder, by constipation, by the mode of dress, and by 
any temporary obstruction to the pelvic circulation. The existence of 
even a marked deviation is often of little moment in itself. A mal- 
position, however, may sometimes render the woman more liable to 
suffer from some accidental complication, from which she might 
escape were the uterus in position. But until the circulation of the 
uterus becomes obstructed from accident, and this condition is super- 
added to the displacement, she may remain long in ignorance of her 
condition. 

KEMAEKS ON DISPLACEMENTS. 

Varieties of Displacements. — These are, first, forward, — ante- 
version and anteflexion; second, backward, — retroversion and retro- 
flexion; third, sideways, — lateroversion and lateroflexion ; fourth, 
downward, — prolapsus; and fifth, inversion. 

L.ofC. 



100 



Displacements of the Uterus. 



As a general rule, it may be stated that anteflexions by far exceed 
in frequency anteversions , anteflexion being to a certain extent merely 
an exaggeration of the normal position of the virgin uterus, whereas 
anteversion is usually the result of changes following parturition. 
In backward displacements, retroversion, on the other hand, is by far 
the more frequent, it being usually found as a consequence of the 
increased weight of the organ and a relaxation of the ligaments follow- 
ing childbirth. Retroflexion, or the formation of an angle at the 
internal os, is commonly a secondary condition, dependent upon the 
downward pressure of a loaded rectum and intra-abdominal atmos- 
pheric influences. Anteflexion may therefore be said to be more fre- 




Fig. 4- — Fibroid Tumor in Posterior Wall of Uterus Simulating Retroflexion. 



quent in the unmarried and in the nulliparous woman, whereas retro- 
version and retroflexion occur more frequently in the woman who has 
borne children; but that both displacements may be found under 
reverse condition, can not be denied. Lateroversion and lateroflexion 
are much less common than either of the other two mentioned varieties. 
Prolapsus of the uterus, in its various degrees, from a mere sagging 
or dropping of the organ to complete extension, occurs, with rare 
exceptions, in parous women, chiefly in those who have borne a large 
number of children. Inversion does not really belong in the category 
of displacements of the uterus, since it is caused by factors entirely 
different from those which produce the dislocations of the organ of 
which we have already spoken. It is mentioned as a matter of com- 



Displacements of the Uterus. 101 

pleteness, and because the organ is of course displaced — that is, turned 
inside out. Fortunately, this condition is not very common. 

Relative Significance of Displacements. — It is conceded on gen- 
eral principles that anteversion is a condition of no particular sig- 
nificance ; neither is anteflexion, unless it is of higher degrees, when 
it may produce either dysmenorrhea or sterility. Retroversion or 
retroflexion in itself may not cause any symptoms whatever ; but in con- 
sequence of the interference with the circulation in the organ, the pro- 
duction of uterine catarrh, the frequently accompanying displacement of 
the ovaries and their tubes, with possible adhesions of the uterus and 
appendages to the adjacent peritoneum, and through interference with 
the caliber of the rectum, in course of time backward displacements 
of the uterus, if of the major degrees, usually do produce symptoms 
which call for relief. Prolapsus uteri, even in the minor degrees 
known as simple descensus, is seldom without significance, because 
women thus affected usually feel the dragging and dropping sensa- 
tion which prevents their being long in an erect position. Lateral 
displacements possess a very slight significance, and are usually con- 
sidered interesting on account of their tendency to produce sterility. 

Causes of Displacement. — Some displacements of the uterus are 
congenital. Thus, new-born children have been found at post-mortem 
to have the uterus either sharply anteflexed or sharply retroflexed or 
retroverted; but these are exceptional cases. The normal antecurved 
position of the uterus naturally tends to facilitate the bending for- 
ward of its body from its point of attachment with the cervix, which 
is the weakest spot in the whole uterine anatomy. There is no ques- 
tion in my mind that the habits of dress which obtain among women 
at the present time, and which, in fact, have existed for many gen- 
erations, are responsible to a very great extent for the anterior and 
downward displacements of the uterus, and chiefly for the anteflexions 
which we so frequently find in young unmarried or childless mar- 
ried women. The compression of the corset on the thorax, and 
mainly on the upper portion of the abdominal cavity, together with the 
pressure of the skirts upon the yielding abdominal walls, — a pressure 
which is by no means counterbalanced by the support the skirts are 
supposed to derive from the hip bones, — this pressure, I am confident, 
by forcing the abdominal viscera downward and forward, does, in 
course of time, produce many an anteflexion and moderate prolapsus. 
Of course if there is a tendency for the uterus to tip backward, as 
may have been the case from childhood, this pressure will increase 
the backward displacement, and the cases of retroversion and retro- 
flexion which we find in virgins and nulliparous women are easily 
explained. 

To understand the peculiar effect of intra-abdominal pressure 
faultily or excessively exerted upon the movable pelvic organs, all we 
have to do is to look at the accompanying diagram of a woman in the 
erect position. The line drawn from her vertex to the upper border 



102 



Displacements of the Uterus. 



of her symphysis pubis strikes just in front of the fundus uteri. Now 
let the small intestines, which normally lie in front of the fundus 
uteri and against the anterior abdominal wall, be forced still farther 
down and forward by compression around the waist, and room is 
given for the fundus uteri to tip forward; the superincumbent intes- 
tines then press the body of the uterus still farther down, until it 
occupies the position believed by some to be the normal one — namely, 
at an angle of 35 degrees with the vagina. It only requires time and a 
continuance of this abnormal pressure to increase the angle of flexion 
at tjie internal os and produce a truly pathological condition. 




Fig. 5. — Relation of Axis of Normal Uterus to that of the Vagina. 



Constipation is undoubtedly also a fruitful factor of displace- 
ments forward, backward, and downward. The full bowel resting 
upon the body of the uterus tends to press it downward. 

Mechanical Supports. — I wish to say a few words here as to the 
use of mechanical supports for the displaced uterus after it has 
been replaced. I know there is a great deal of difference of opinion 
as to the value and uses of mechanical supporters, or pessaries, as 
they are generally called, in the treatment of uterine displacements. 
Some authors whose experience can not be denied, and whose 
opinions must be respected, utterly denounce them and never 
employ them. Others, again, of equal eminence and experience, 



Displacements of the Uterus. 103 

do not see how they can do without them, and use them daily. 
Disagreeable and in many ways obnoxious as all forms of uterine 
supporters undoubtedly are, it seems to me that the question is simply, 
in a large proportion of displacements of the uterus, notably of the 
backward varieties, whether we shall allow the displacement to remain 
untreated and the patient unrelieved or subjected to frequent and 
annoying manipulations, or whether, on the other hand, we shall 
replace the organ, keep it in position by a properly-fitting supporter, 
and give the patient complete relief, the only drawback being an 
occasional visit to the office for the purpose of supervising the case 
and cleansing the instrument. A woman with a badly retroverted or 
retroflexed uterus finds great relief from a well-fitting vaginal pessary. 
Not every patient who has a displacement of the uterus wishes to be 
operated on for its permanent cure, and for such cases I think mechan- 
ical support, by pessaries, of the replaced organ, is indispensable when- 
ever it can be safely employed. Prolapsus, of course, does require 
mechanical support, but the results are by no means as satisfactory as 
in retro-displacements. We know that mechanical supports do not 
cure displacements. They relieve; they keep the uterus in position; 
they give the ligaments a chance to regain their tone. They may, in 
cases where the relaxation is not severe, and where the displacement 
is not of long standing, in the course of a few months or a year enable 
the ligaments and supports to become so strong that when the pessary 
is removed the uterus remains in its normal position. I wish to state 
also that there are some women who can not wear a pessary, but are 
made very comfortable with a well-fitting tampon made of absorbent 
cotton. The patient can remove these at will, and adjust another 
daily if necessary, by getting into the proper position (knee and chest). 
Her physician can easily instruct her as to the procedure. Electricity 
has proved a valuable aid in my hands in strengthening and giving 
tone to the uterus and its ligaments. 

ANTEVERSION. 

Definition. — Anteversion ("to turn") is a displasement of the 
uterus in which the fundus is turned toward the pubes, while its ori- 
fice is toward the sacrum. It may be caused by extraordinary size of 
the pelvis or pressure of the viscera on the uterus. Anteflexion 
is a simple forward inclination of the body of the uterus, without the 
os uteri being carried much backward. 

Degrees of Anteversion. — There are accepted two degrees of ante- 
version, — the first in which the uterine axis is at an angle of 30 
degrees with the vagina, and the second in which the uterine angle 
is still further lessened, until it and that of the vagina are parallel. 
Dr. Beigel, in his classical work on sterility, depicts a uterus ante- 
verted to that degree. Anteversion and anteflexion may exist at the 



104 Displacements of the Uterus. 

same time, as may also anteversion and a moderate degree of pro- 
lapsus. 

Causes. — The causes of anteversions of the uterus are usually 
increased weight of the organ, produced by subinvolution, hypertrophy, 
fibroid tumors of the anterior uterine wall, and pregnancy, and are gen- 
erally accompanied by other factors which allow the anteverted uterus 
to sink down in the cavity of the pelvis, namely, relaxation of the liga- 
ments and supports. Thus a heavy uterus with relaxed broad liga- 
ments and flabby vaginal walls will, if not naturally inclined rather 
forward, have a tendency to antevert and sag into the pelvic cavity. 
A pendulous abdomen with increased superincumbent abdominal 
pressure will increase this tendency to anteversion and prolapsus. 

Frequency. — In my experience, anteversion is by no means as fre- 
quent as anteflexion. Usually when I find the uterus to be ante- 
verted, a minor degree of prolapsus (as I have already said) is associ- 
ated with it. I find that whenever an anteversion produces decided 
symptoms, these symptoms may be attributed quite as much to the 
coexisting downward displacement of the uterus as to the anteversion. 
But rarely does the pressure on the bladder produced by an anteverted 
uterus alone induce the patient to consult a physician. 

Symptoms. — The symptoms of anteversion have already been 
touched upon in the preceding remarks. The pressure on the blad- 
der, bearing-down sensation in the erect or sitting postures, and a 
certain uncomfortable dragging feeling in the pelvis when walking, 
are the most prominent. 

Diagnosis. — The diagnosis of anteversion is very easy. One has 
but to find the body and fundus of the uterus close to or touching the 
symphysis pubis, or even below it, — that is, the uterine axis parallel 
to the vaginal canal and the cervix pointing toward the middle or 
upper portion of the sacral excavation, — in order to determine the 
existence of an anteversion. Bimanual palpation, of course, is essen- 
tial to the formation of the diagnosis, as it is to that of the majority 
of uterine displacements. 

Complications. — Besides the almost invariable presence of pro- 
lapsus in the first degree, together with enlargement of the body of 
the uterus, I have only to record the presence of an interstitial or 
subperitoneal fibroid tumor in the anterior wall of the uterus as a 
not very rare complication of this displacement. Anteflexion may be 
present at the same time with anteversion, but will, as a rule, not 
materially alter the description and symptoms already given. 

Treatment. — If possible, all complications should be removed. 
In fresh cases, the packing of the vagina with wool tampons dipped 
in iodoform and tannin powder (equal parts), or glycerite of tannin, 
the woman at the same time occupying the knee-chest position, may 
succeed in restoring tone to the anterior vaginal wall and the attach- 
ment of the bladder, and in thus curing the anteversion, particularly 




Plate a. — Cystocele and Reetocelt 



Displacements of the Uterus. 



105 



if a prolapse of the anterior vaginal wall with the posterior wall of 
the bladder (so-called cystocele) is present at the same time. A well- 
fitting abdominal bandage or brace assists the vaginal tampons by push- 
ing the abdomen upwards, thus preventing the weight of the bowel from 
resting so heavily upon the anteverted uterus. The patient should 
lie on her back to rest. The rest cure is very essential in these cases. 



ANTEFLEXION 



Definition. — This is a simple forward inclination of the body of 
the uterus, without the os uteri being carried much backward; that 




Anteflexion, First Degree. 



is to say, the body of the uterus may be bent down upon the cervix, 
and this is called anteflexion of the body, or the cervix of the uterus 
may be bent upward toward the body, and this is called anteflexion of 
the cervix. 

Causes. — As I have already stated under general remarks, an 
anteflexion of the uterus is but an exaggeration of the normal ante- 
curved position of the organ. It is thought that the tendency to this 
exaggeration undoubtedly is congenital; that is to say, the child is 
born and developed with a weak spot in her uterus, and that is the 
junction of the body and the cervix. Either she has the anteflexion 
at birth or it is developed in the course of growth under the influences 
of dress, posture, constipation, etc., which have already been touched 



106 



Displacements of the Uterus. 




Fig. 7. — Anteflexion, Second Degree. 




Fig, 8. — Anteflexion, Third Degree. 



Displacements of the Uterus. 



107 




Fig. 9.— Anteflexion with Retroposition . 




Fig. 10.— Anteflexion of the Cervic 



108 Displacements of the Uterus. 

upon under general remarks. The one displacement of the uterus 
which is met with in young, unmarried, childless women with the 
greatest frequency is anteflexion. The causes of anteflexion may be 
summed up briefly to be either congenital — probably the minority — 
or acquired — undoubtedly the majority — but the latter depending 
mostly upon a congenital predisposition. A fibroid tumor, however, 
developing in the anterior or posterior wall of the body of the uterus 
may produce an anteflexion by its weight. In unmarried and sterile 
women anteflexion is by far the most common form of displacement. 

Diagnosis. — Bimanual examination will very easily enable the 
physicians to make the diagnosis of the flexions in any one of the 
degrees mentioned. A small fibroid tumor situated in the uterine wall 
may simulate an anteflexion; and when that is the case, only a very 
careful examination, together with the use of the sound, will enable 
the examiner to make the diagnosis. An increase in the size of the 
body of the uterus will naturally contribute to a correct understand- 
ing of the case. The caliber of the external and internal orifices of 
the uterine canal can, of course, only be ascertained by the introduc- 
tion of the uterine sound. It is distinctly understood that the differ- 
ential diagnosis between a version and a flexion consists in this, that 
in a version the uterine canal is straight, no matter how much it may 
deviate from the vaginal axis, but that in a flexion there is a more or 
less sharp angle in the canal at a point corresponding to the internal os. 

Symptoms. — Aside from dysmennorhea and sterility, an uncom- 
plicated flexion produces no symptoms. But there are certain com- 
plications which may be present, even in the minor degrees of flexion, 
which do produce symptoms, and such complications are a chronic 
catarrh of the uterine mucous membrane, so-called chronic endo- 
metritis, and a spasmodic contraction of the circular fibers at the 
internal os. The first of these conditions will produce dysmenorrhea 
of the congestive variety; second, dysmenorrhea of the obstructive 
or neuralgic variety, both being possibly associated in the same case. 

Treatment. — The treatment is given under the head of dysmen- 
orrhea. 

RETROVERSION. 

Definition. — Retroversion is a change in the position of the 
uterus, so that the fundus of the organ is turned toward the concavity 
of the sacrum, while the neck is directed toward the symphysis pubis. 

Causes. — Backward displacements of the uterus occur most fre- 
quently in women who have borne children. Its usual period of occur- 
rence is between the third and fourth month of pregnancy, before the 
uterus has escaped above the superior aperture of the pelvis. A 
fibrous tumor in the posterior wall of the uterus may simulate a retro- 
version or retroflexion, if the uterus has a tendency to drop backward. 
Prolonged and difficult labors, lacerations of the neck of the womb, 



Displacements of the Uterus. 



109 



with subsequent subinvolution of the organ, — that is to say, a more 
or less permanent increase in its size and weight, together with sub- 
involution of the suspensory ligaments of the uterus, and very often 
of the inferior supports, the vagina and perineum, — these are among 
the most common and potent factors in this displacement. It is not 
necessary that the perineum should be torn in order that the vagina 
may be relaxed and prolapsed, and thus one of the inferior supports 
of the uterus be removed ; a mere want of involution of the perineum, 
that is to say, a failure of the organ to regain its normal tone and 
strength, is equivalent to an absolute loss of the part. If the bladder 




Retroversion, First Degree. 



and rectum also prolapse, there is still less support for the uterus from 
below; and once a descent of the organ into the cavity of the pelvis 
having taken place, a backward tipping of its body is an almost inev- 
itable result. 

Retroversion or retroflexion is frequently found in women who 
have never borne children and who are even virgins. The explana- 
tion for the occurrence of the displacement in these cases must be that 
either the woman grew up with the displacement, in which case a 
congenital shortening of the utero-recto-sacral ligaments may be sup- 
posed, or else that some sudden physical shock, such as a sharp fall on 
the buttocks, may have caused the backward displacement. 



110 



Displacements of the Uterus. 




Fig. 12. — Retroversion, Second Degree. 




Fig. 13. — Retroversion, Third Degree. 



Displacements of the Uterus. 



Ill 



Significance. — There is some difference of opinion as to whether 
a backward displacement of the uterus has in itself any particular 
significance in the production of local pain or reflex symptoms. If 
the uterus is small and movable, and the ovaries are not prolapsed 
with it, a backward displacement of the second or third degree, either 
version or flexion, may exist for years without in any way attracting 
the attention of the patient ; but as regards this class of cases it is the 
exception for a uterus to be retroverted or retroflexed in the second 
or third degree without, in the course of time, an adhesion of the 
fundus, or a prolapsus and adhesion of the appendages, to occur, or 
a uterine catarrh to supervene, in consequence of the changes of the 




Fig. 14- — Retroflexion of the Uterus. 



circulation produced by the displacement; and then inevitably come 
the symptoms peculiar to the aggravated forms of this displacement. 
It is not the displacement alone which produces pain, local and general, 
and the other symptoms peculiar to the displacement, but the complica- 
tions produced by and naturally following the condition. Should a 
uterus retrovert during the first two months of pregnancy, or should a 
retroverted or retroflexed uterus become pregnant, as occasionally does 
occur, the significance of the displacement very soon becomes decidedly 
marked. The growing organ soon finds the pelvic cavity too limited, 
and, being prevented by the promontory of the sacrum from rising 
into the abdominal cavity, begins to rebel. Incarceration of the 
pregnant uterus has taken place, and uterine contractions, hemor- 



112 



Displacements of the Uterus. 




Fig. 15. — Reposition of Retroflexed Uterus in Lejl Lateral Position, First Step. 




Fig. 16.— Reposition of Retroflexed Uterus in Dorsal Position. 



Displacements of the Uterus. 



113 




Fig. 17, Reposition of Retroflexed Uterus in Left Lateral Position, Second Step. 




Fig. 18. — Reposition of Retroflexed Uterus in Left Lateral Position, Third\Step. 



114 Displacements of the Uterus. 

rhage, and abortion are inevitable results, unless the displacement is 
speedily rectified and the uterus kept in place by a properly-fitting 
supporter. Besides the usual symptoms produced by backward dis- 
placement, sterility may be considered a very frequent result. 

Symptoms. — Whenever a uterus is retroverted or retroflexed. in 
the second or third degree, and the displacement has persisted for 
some months or years, the patient is likely to complain of a bearing- 
down, a dropping sensation in the pelvis during standing or walking, 
pain in the lower part of the sacrum and coccyx, perhaps extending down 
the back of either thigh along the sciatic nerve, an inability to walk 
any distance or stand for any length of time, leucorrhoea, often pro- 
fuse menstruation. Besides, if the ovaries are prolapsed at the same 
time, there will be a more acute pain than is common in retrodis- 
placement alone in the region of each sacro-ischiatic notch. These 
are the local symptoms. The reflex symptoms are exceedingly varied 
and profuse, and may be classified under the heading of general 
neurosis of the nervous system — not neuralgia or pain, because the 
disturbances are not always actually painful. Thus, a woman with 
an aggravated retroversion or retroflexion may have hemicrania, 
frontal, vertical, or occipital headache, intercostal neuralgia, gas- 
tralgia, nausea, and vomiting, or may feel generally depressed and 
nervous, without any special localized pain. When retroversion and 
retroflexion do cause discomfort, they do so by pressure on the rectum 
or in the lower part of the back, interference with evacuation of the 
fasces. 

Diagnosis. — The diagnosis can only be made by a vaginal exam- 
ination. The body of the uterus will be found either horizontal on 
a line with the axis of the vagina (first degree), or tipped backwards 
more or less into the excavation of the sacrum, with the cervix point- 
ing upward towards the anterior wall of the vagina in retroversion, 
or in the axis of the vagina, with an angle at the junction of the cervix 
and body, in retroflexion. The acuteness of the angle will designate 
the degree of flexion. Bimanual palpation will show that the body 
of the uterus is absent from the position which it should naturally 
occupy. In case of doubt, the sound or probe will verify the diag- 
nosis of backward displacement. If the uterus is not adherent, the 
examining finger will be able to lift up the body of the organ, and 
possibly even restore it to its normal position by the aid of the other 
hand pressing through the abdominal wall. If the ovaries and tubes 
are prolapsed at the same time, they will be found lying to either 
side or immediately behind the body of the uterus. If the uterus 
is adherent or impacted between the utero-recto-sacral ligaments, it 
is not replaceable, and the diagnosis may become doubtful. It is 
necessary to remember that bimanual palpation is absolutely essential 
to the diagnosis of retroversion and retroflexion, as, indeed, it is to 
nearly all the other displacements of the uterus. 




Plate J). — Sims Position. (Potter.) 




Plate c. — Knee-chest Position. (Potter.) 



Displacements of the Uterus. 115 

In making differential diagnosis, it is necessary to remember there 
are other bodies besides the corpus uteri which occupy Douglas' pouch 
and simulate a backward displacement. These are fibroids, small 
ovarian tumors, plastic exudations, effusions of blood, and abscesses. 
In such cases the sounding of the uterus may be necessary to make 
the diagnosis, and even then the most experienced touch may be at 
fault. 

Treatment. — The treatment comprises simply two main points, 
first, the restoration of the displaced organ to its normal position, and, 
second, its retention therein. 

First, the elevation of the retro-displaced uterus may be accom- 
plished by the fingers, posture, and instruments (sound and repositor). 
In case the retroversion is due to pregnancy, it being the second, or 
between the third and fourth months of pregnancy, before the uterus 
has escaped above to the superior aperture of the pelvis, the catheter 
must be regularly used every eight hours, or twice in twenty-four hours, 
until the uterus, by its growth, rises above the pelvis. The bowels 
must be kept open, and absolute rest in a recumbent posture be 
enjoined. Should it be impracticable to draw off the urine, attempts 
must be made to replace the uterus. The woman being on her hands 
and knees, the fore and middle fingers of the accoucher's left hand 
are to be passed up the rectum to the fundus uteri, which they must 
elevate, while the cervix uteri is carefully depressed by two fingers of 
the right hand in the vagina. Should the fingers employed to elevate 
the fundus not be long enough to effect this object, a piece of whale- 
bone may be substituted, to which a small piece of sponge is attached 
as a pad, or a repositor may be used. When a woman is not preg- 
nant, the dorsal recumbent position is preferred. With one or two 
fingers in the vagina, the operator may elevate the uterus until the 
fingers of the other hand can grasp the fundus through the abdominal 
wall and tilt it forward. This is possible only in very thin and lax 
abdominal walls. The usual method of replacing a retro-displaced 
uterus is by putting the patient in the left latero-abdominal position 
(Sims'), inserting the index and middle fingers of the right hand into 
the vagina, and, standing well behind the patient, pressing the body 
of the uterus upwards until it is so far elevated that the fingers can 
barely touch the fundus. Then the index finger is passed in front 
of the cervix and draws that part backwards, while the middle finger 
still remains in the posterior pouch. By thus gradually drawing the 
cervix backward and pushing the fundus upward, the body of the uterus 
is slowly tipped forward into the normal anteverted position. Should 
this manipulation fail, the woman may be put in the knee-chest posi- 
tion, and with atmospheric pressure efforts made to dislodge the body 
of the uterus from the sacral excavation by the means of the fingers 
passed into the vagina, or, in extreme cases, into the rectum, or a 
Sims' depressor or sponge or cotton on a holder may be used as a 



116 Displacements of the Uterus. 

means of exerting pressure on the retroverted organ. At times the 
elevation of the perineum by a Sims' speculum, and the drawing down 
of the cervix by a tenaculum hooked into it, may succeed in dislodg- 
ing the fundus from its impacted position in the sacral cavity, and 
then the pressure of air exerted with special force on the vaginal vault 
with the woman in this position, will aid in replacing the uterus. 

The uterus having been replaced by any one of these methods, it 
should be at once retained in its now normal position by a properly- 
fitting support, or by balls of cotton or gauze packing. 

^Should the uterus be found unreplaceable by any of these measures, 
it may be safely inferred that it is adherent, and nothing short of 
operative interference will succeed in replacing it. 

LATEROVERSION AND LATEROFLEXION. 

Definition. — A uterus is said to be lateroverted or lateroflexed 
when its body is tipped or bent to one side or the other of the median 
line. 

Causes. — These displacements are either congenital or acquired, 
in either case through a shortening of the broad ligament of the side 
toward which the body tips. The reasons for congenital shortening 
of the broad ligaments are not known; those of acquired shortening 
are simply the contraction following an inflammation involving the 
affected broad ligament. 

Diagnosis. — The diagnosis is easy, being made by bimanual 
examination, aided, if necessary, by the sound. 

Treatment. — Persistent use of tampons, so as to stretch the con- 
tracted ligaments, and the use of electricity, offer the only reasonable 
chances of success. 

PROCIDENTIA, OR PROLAPSE, OF THE UTERUS. 

Definition. — A prolapsus is a falling down of the uterus, owing 
to relaxation of the parts about the utero-vaginal region. This con- 
dition may exist in any degree, from a simple dragging of the organ 
to the entire escape of the uterus from the vagina. 

Causes. — The immediate causes of prolapse are threefold, — either 
some growth above the uterus crowds it downward, or there is an increase 
of weight in the organ itself, or there is a want of proper support 
below. The first step in the process is usually to be traced directly 
to the absence of support for the vaginal walls at the outlet of the 
passage, from which a further descent is soon induced by the increase 
in weight of the organ, resulting from its malposition. To what- 
ever cause the increase in size and weight of the uterus may be due, 
the organ will settle into the pelvis just in proportion to the additional 
burden. 

Complete procedentia is essentially a condition of middle life 



Displacements of the Uterus. 



117 




Fig. 19.-^-Degrees of Prolapsus Uteri (Diagrammatic). The First Shows Normal 
Position with Correct Uterine and Vaginal Axes. 




Fig. 20. — Section of Complete Prolapse of Uterus and Vagina. 



118 Displacements of the Uterus. 

or old age, and occurs usually in those who have given birth to more 
than the usual number of children. We have met with complete pro- 
cidentia, due to fibrous polypus, in which the displacement was caused 
by uterine contraction. 

A patulous state of the vulva must be present in every instance 
before the procidentia can become complete. If the pressure from 
above is sufficient to crowd the retroverted uterus down against the 
vaginal outlet, this will become gradually distended, and the neigh- 
boring tissues so thinned out from absorption as no longer to offer 
sufficient resistance. 

* The effects of childbirth are considered as the most common of 
all causes in producing procidentia. In all these cases the neck of 
the uterus becomes lacerated; and whenever this accident occurs, it 
will always keep up a sufficient irritation to arrest the involution or 
natural decrease in the size of the organ after childbirth. The 
increased weight of the uterus causes it to descend and rest upon the 
floor of the pelvis, where it acts as a wedge to keep the vagina dilated ; 
and the cervix soon presents at the vaginal outlet. Frequently the 
same causes which produce laceration of the neck of the uterus will 
also open the vaginal outlet, and when this accident has occurred to 
an unusual degree, so little resistance is opposed to the descent of 
the uterus that the procidentia soon becomes complete. 

Frequency. — Suffice it to say that prolapsus uteri in the minor 
degrees, associated with both anteversion and retro-displacement, is 
one of the most common forms of malposition of the uterus. In its 
second and third degrees it is also very common, being confined almost 
exclusively to the parous woman. 

Significance. — The greater the degree of prolapsus, the greater 
its influence upon the comfort of the woman. Prolapsus of the first 
degree will probably produce but very slight discomfort, except the 
feeling of weight and bearing down which it entails. The incon- 
venience of prolapsus of the second degree is greater in proportion, 
and that of the third degree need merely be mentioned to be appre- 
ciated. A woman with a uterus and vagina hanging between her 
thighs; with the external os lacerated, eroded, bleeding, discharging; 
with the prolapsed vaginal walls toughened and ulcerated in places; 
and with the constant sensation of losing all her "insides," so to speak, 
is indeed in a deplorable condition. But we must not forget that, 
besides the uterus, the bladder and rectum are also prolapsed, and 
it is the bladder chiefly which gives rise to decided symptoms. The 
stagnation of the urine in the prolapsed portion of the bladder causes 
decomposition of that fluid, irritation of the vesical mucous membrane, 
and, in time, cystitis, which is in itself quite sufficient to render the" 
patient miserable, irrespective of the prolapsus of the uterus and 
rectum. Further, accumulation of faeces in the prolapsed portion of 
the rectum may also give rise to more or less inconve ience. 



Displacements of the Uterus. 119 

Diagnosis. — The diagnosis of prolapsus of the uterus is exceed- 
ingly easy. It requires merely a practised finger to be enabled to 
determine that the cervix uteri is lower in the pelvic cavity than it 
should be ; with a large ovoid, glistening, more or less eroded body lying 
outside of the vulva, a complete prolapse of the uterus and vagina 
is easily diagnosed. A sound passed into the uterus will verify the 
fact that it is the uterus which is prolapsed. Still, there may be an 
opportunity for error as regards the presence of a true prolapse, as 
the supravaginal portion of the cervix may be hypertrophied, and, 
having grown downwards, together with the attached anterior and 
posterior vaginal walls, may simulate a real prolapsus of the uterus, 
whereas the condition is one of hypertrophy of the cervix and pro- 
lapse of the vagina, the body of the uterus remaining about at its nor- 
mal altitude in the pelvis. The sound introduced into the fundus 
uteri will reveal the correct diagnosis, since it will be found that two- 
thirds of this seemingly-prolapsed organ is cervix and only one-third 
body, and that the fundus retains its normal elevation in the pelvic 
cavity. 

Prognosis. — Taken as a rule, prolapsus uteri of the first and 
second degrees, unless relieved by proper mechanical and operative 
procedure, will eventually result in a prolapse of the organ to the third 
degree. A cure of the displacement is scarcely to be expected by 
natural means, — that is to say, by a spontaneous restoration to the 
normal position, — with one exception, namely, the possibility that 
the processes of involution which follow parturition may, under 
proper precautions, restore the uterus and its ligaments to their nor- 
mal position and tone. There is nothing necessarily prejudicial to 
life in prolapsus uteri of any degree, and a woman with her uterus 
and vagina dangling between her thighs may thus attain the age of 
eighty or more years, so far as this pathological condition is con- 
cerned. 

Treatment. — The treatment, of prolapsus uteri is either palli- 
ative or radical. Among the palliative measures for the minor degrees 
of prolapsus are, in the recent cases, astringent injections, tampons 
applied to the vagina, chiefly in the knee-chest position, with the view 
to contracting the parts and restoring them to their normal tone. As 
prolapsus in the minor degrees is associated with anteversion and 
retro-displacements, the pessaries, tampons, and the Faradic current 
of electricity are useful for these forms of prolapsus. When it comes 
to a prolapsus of the second and third degrees, with the use of 
astringent injection, and tampons made of cotton dipped in an 
astringent iodoform and tannin (equal parts), with the woman in the 
knee-chest position, and with the atmospheric pressure, the uterus is 
more or less reduced. Place two or three of these tampons well up 
around the uterus ; the hips must be elevated, and the woman should 
keep the recumbent position for an hour or two after each treatment. 



120 



Displacements of the Uterus. 



If the tampons should slip down, they may be removed and larger ones 
applied, the patient wearing a T bandage. A well-fitting abdominal 
bandage or body brace is useful in these cases. The woman, with 
instructions from her physician, can do this herself. 

Pessaries. — They all, in course of time, cause excoriation and 
ulceration of the vaginal wall where they exert their pressure, and have 
to be removed until the wound is healed. None of them ever pro- 
duces a cure ; but they give, comparatively, some relief. The varieties 
of pessaries used for these displacements are hard rubber, glass, or 
wooden rings; aluminum is a good metal for this purpose. 

Operative Treatment. — The diminution in size of the uterus can 
be attained by two measures, namely, amputation of the cervix or 
repair of the laceration of the cervix. 

The closure of the laceration of the cervix should be practised 
in every case of prolapsus, no matter of what degree. Its object is 
not only to restore the cervix to its normal condition, and cure such 
uterine catarrh as may be present, but also to stimulate the organ to 
a diminution in size — a result which is well known to follow this 
operation. 



INVERSION OF THE UTERUS. 



Definition. — By inversion of the uterus is meant a more or less 
complete turning inside out of the body of the organ, so that in the 
complete degree the fundus uteri occupies a position lower than that 
of the cervix. 

Causes. — These are either acute or chronic. The chief cause of 
acute inversion of the uterus of the complete variety is puerperal, the 

fundus uteri either being forced through 
the cervix into the vagina by spontaneous 
contractions of the uterus or by traction 
on the cord of the adherent placenta by, 
the obstetric attendant. The chief cause 
of chronic inversion of the uterus, either 
of the incomplete or the complete variety, 
is the forcing downwards by uterine con- 
tractions of a fibroid tumor situated near 
the fundus uteri (usually incomplete in- 
version), and the drawing through the 
cervical canal of the tumor and the fundus, 
by instruments in the hand of the operator 
(complete inversion). When a fibroid tumor inverts the uterus, so 
long as the inversion is complete, it usually starts from one side of 
the uterus where the tumor happens to be attached. It is only when 
the efforts of nature alone force the tumor down into the vagina, or 
the operator draws it down, that the inversion becomes complete. 
Chronic inversion of the uterus, either partial or complete, may occupy 
a number of months in its accomplishment. 




Incomplete Inver- 
sion of Uterus. 



Complete Inver- 
sion of Uterus. 



Displacements of the Uterus. 121 

Frequency. — Puerperal inversion is not commonly met with by 
the gynaecologist, because at the present day general practitioners are 
more apt to make a physical examination if anything unexpected 
occurs, and, therefore, discovering the inversion, proceed at once to 
rectify it. Complete inversion of the chronic variety is frequent in 
proportion to the forcing or drawing down of the tumor into the 
vagina, either before or during the operation for its removal. 

Significance. — Inversion of the complete variety, when of puer- 
peral origin, is of supreme importance, since the symptoms it pro- 
duces, — that is, chiefly prolonged and violent hemorrhage, — weaken 
the patient so much that she will eventually succumb to the strain 
if not relieved. Inversion of the non-puerperal variety is in itself 
of little consequence, since it is but the result of another more serious 
causative element, namely, the fibroid tumor, which, to be sure, pro- 
duces the same symptoms, namely, hemorrhage; but on removal of 
the tumor, if this can be done without injuring the uterine wall, the 
reposition of the inversion is easily effected, and the displacemnt in 
itself loses all significance. 

Symptoms. — The symptoms of inversion are comprised in one 
word, hemorrhage, whether the hemorrhage comes from simple inverted 
uterus or from the fibroid tumor complicating and producing the inver- 
sion. Bearing down, feeling of weight, "dropping" sensation in the 
pelvis, are natural symptoms. 

Diagnosis. — A patient presents herself for vaginal hemorrhage, 
and examination reveals a pear-shaped, oblong body, more or less fill- 
ing the vaginal canal, and terminating above in the circle of the cervix 
uteri. This body bleeds on manipulation, is soft, semi-elastic to the 
touch, more or less painful. Bimanual palpation, if it can be thor- 
oughly carried out, shows an absence of the uterine body in its nor- 
mal position above the pubis. A sound passed into the groove within 
the circle fails to enter the uterine cavity. The peculiar-shaped 
body in the vagina, the absence of the body of the uterus above the 
pubis, the failure of the sound to enter into the uterine cavity, — these 
three points combined make the positive diagnosis of inversion of the 
uterus. A rectal examination can, if necessary, be made to confirm 
the absence of the body of the uterus in its normal position. In com- 
plete inversion a more or less irregular body is felt in the vaginal 
canal; on bimanual examination an irregular mass corresponding to 
the body of the uterus, but indented on one side, is felt above the 
symphysis pubis, and the sound enters to a limited depth, that is, 
instead of two and a half inches, only one and a half or two inches. 
The sound will enter to the opposite side from where the depression 
is perhaps to its normal depth, showing that the depth of the uterine 
cavity on the side of the depression is diminished. This would natu- 
rally point toward a partial inversion. 

Differential Diagnosis. — A tumor corresponding exactly in shape 



122 



Displacements of the Uterus. 



and size to the inverted uterus may be found in the vaginal canal; 
the relations of it to the cervix and its ring are exactly similar to 
those of inversion, and the uterine sound does pass into the canal. 
The thick walls may not allow the examiner to clearly map out the 
body of the uterus, supposing it to be in its normal position. The 
vaginal tumor is not particularly sensitive, whereas the inverted uterus 
usually is quite tender to the touch; but it bleeds, and the patient's 
history does not give any distinct information as to the occurrence 
of this condition. When one is in doubt as to the diagnosis being 
correct in such cases, it is a safe plan not to attempt to remove the sup- 
posed polypus, but to submit the patient to another examination, with 
a consultation with a specialist, to arrive at a true conclusion, and 
proceed accordingly. To amputate the inverted uterus would be a 
great and almost criminal error; and to attempt to replace a uterine 
polypus would be about as grave an error, certainly a very ridiculous 
one. 

Treatment. — An acute inversion of puerperal origin does not 
occur often. We may, of course, state that its immediate return is the 
only proper treatment, and that a neglect to do so is a grave error on 
the part of the practitioner. Chronic complete inversion should, of 
course, be reduced as soon as recognized. 

The methods for such reduction are manual, instrumental, and 
operative. Dr. P. Monde's manual method consists in placing the 
patient under an anaesthetic, and with the hand in the 
vagina and compressing the body of the uterus, either 
pushing the fundus upward or first attempting to re- 
turn one horn or the other, while the fingers of the 
other hand exert counter pressure through the ab- 
dominal walls, and attempt to dilate at the cervix, 
which forms the great obstacle to the reposition of 
the organ. • Emmet and Sims recommended pushing 
the fundus uteri straight up; ISToeggerath first ad- 
vised pressing up one of the horns of the uterus. The 
object is to dilate with the outer fingers the infundibu- 
lum, or ring of the cervix, sufficiently to enable the 
vaginal fingers to press the inverted body through it. 
Once the ring is passed by a certain portion of the 
body of the uterus, its complete reposition is easily 
effected. This manipulation is by no means as easy 
as it seems to be. 

Instrumental. — Wing, of Boston, succeeded in 
the reduction of an inverted uterus with a very in- 
genious device represented by a conical plug, surmounted by a thick 
rubber ring, which was passed into the vagina over and against the 
fundus, and to the outer end of which were attached stout rubber tubes, 
which were again fixed to the posterior surface of a band passed around 
the waist of the patient. The steady pressure exerted by the elastic 




Fig. 22. 

Polypus Simulating 

Camplete Inversion 

of Uterus. 



Displacements of the Uterus. 123 

traction of these tubes upon the plug in the vagina succeeded, after 
twenty-four hours or more, in gradually overcoming the resistance of 
the cervical ring against the return of the uterus, and the reposition 
of the inverted organ was thus effected. Packing the vagina with wool 
or cotton wads or antiseptic gauze has also been effectual in gradually 
reducing an inverted uterus. 

Operative. — Amputation of the inverted uterus should always 
be considered as a last resort, to be performed only when all other 
measures have failed. If amputation is to be done, Dr. Monde rec- 
ommends the elastic ligature as superior to any other method, because 
it gradually, by adhesive agglutination, closes the peritoneal cavity; 
and when the stump sloughs away, there is no danger of infection of 
the peritoneum. 



CHAPTEK VI. 

FUNCTIONAL DISEASES— DISORDERS OF THE UTERINE 

FUNCTIONS. 

Menstruation. — One of the special functions of the uterus, which 
ma/ be deranged in several ways, as, more or less absent in amenorrhea, 
more or less excessive in menorrhagia, or painful in dysmenorrhea. 
They are not distinct diseases of the uterus, but derangements of its 
functions, which are expressive of many conditions, both general and 
local. Pathological conditions quite different, and even dissimilar, may 
enter into their causations, as in cough and dropsy, which are only symp- 
toms. The underlying morbid conditions which give rise to them 
must be looked for. In many of these cases there are difficulties in 
the way of a thorough investigation. However, fortunately very cor- 
rect inference can be drawn as to their underlying causative factors, 
from the symptoms of the case and from the age and social condition 
of the patient. On the other hand, at times a direct and thorough 
examination of the organs concerned is absolutely necessary for a 
rational treatment. A successful and scientific treatment of these func- 
tional disorders in all their manifestations implies a thorough knowl- 
edge of gynaecology. 

Amenorrhoea. — Meaning absence of menstruation, which has 
technically speaking, an absolute and relative application. Absolute 
amenorrlioea means a complete absence of menstruation, and implies 
a duration of at ieast several months, even years. Relative amenor- 
rhea denotes menstruation which is delayed, or scant, and comes on at 
prolonged intervals. Again, the term applies to those who have never 
menstruated, a condition called "emausio-mensium." Cessation of the 
function after it has once been established is called "suppressio men- 
sium." Amenorrhoea is a normal condition during pregnancy and lac- 
tation ; but it is abnormal when, from the age of fifteen to that of forty- 
five, there jsa menstrual suppression, not from pregnancy or lactation, 
but from nature or disease. 

Etiology. — The general causes are, in acute disease, as follows: 
The menstrual flow usually ceases during convalescence from acute dis- 
eases, on account of the general debility and anaemia ; hence its return 
is always an indication of a return to health. 

Chronic diseases, depressing and exhausting in their nature, cause 
menstrual suppression. 

Among these may be noticed chronic disease of the liver, the stom- 
ach, the intestines, the kidneys, and especially the lungs. Tuberculosis 
(124) 



Functional Diseases — Disorders of the Uterine Functions. 125 

affords a typical manifestation of amenorrhea, almost always a lung 
disease. In most of these constitutional diseases the menstrual flow 
becomes more and more irregular, the intervals being lengthened. In 
chronic albuminuria, or general cancer, amenorrhoeic anemia, chlorosis, 
malaria, syphilis, and general struma, the general organs lack sufficient 
nourishment to carry on this function, and they are followed by 
amenorrhea. Defective hygiene causes it. In some of these condi- 
tions there may be no sanguineous discharge, but, instead, a profuse 
muco-purulent leucorrhoea. All cachexias are constitutional causes of 
amenorrhea. 

Physical causes are not uncommon ; sudden and unexpected news, 
fright, grief, and great anxiety are causes of this menstrual disorder. 
An abrupt change in the place of living, associations, and climate fre- 
quently cause it. Young ladies who go from home to a boarding-school 
are apt to have amenorrhea ; so are immigrants to this country. There 
must be some change in the nervous system through the emotions. This 
is sometimes the case with the newly married, who have suspected the 
possibility of pregnancy. The fear of pregnancy following illicit coitus 
not infrequently leads to temporary amenorrhea. All these condi- 
tions, it is said, can properly be called physical amenorrhea. Insanity 
is almost always associated with amenorrhea. 

The local causes of amenorrhea are an absence or a very imper- 
fect development of the uterus. The uterus is oftener imperfectly 
developed than any other of the genital organs, certainly much more 
frequently than the ovaries. This condition is sometimes found when 
the whole physique is otherwise matured. Then there is also, of course, 
sterility. The uterus may be fairly well developed, but its growth 
delayed. The ovaries may be absent or illy developed, so that the sex- 
ual changes at puberty have not taken place. Such a condition is usu- 
ally associated with the absence of, or imperfect anatomical and physio- 
logical changes of, the uterus, tubes, and vagina. 

Attresia. — Attresia, congenital or acquired, are generally causes 
of menstrual retention, but not of menstrual suppression. There is 
far greater intolerance from the acquired than from the congenital 
causes. An imperfect hymen is the most frequent and least dangerous 
of these malformations. 

Diseases of the ovaries do not rank first in frequency and impor- 
tance as local conditions creating amenorrhea. Rarely acute or 
chronic ovaritis causes this symptom, and cystic degeneration, passing 
on to the formation of a tumor, seldom does so. Women with large 
ovarian tumors become amenorrheic towards the last, from a serious 
drain on the general health. 

Chronic metritis, in its third stage of cirrhosis or uterine atrophy, 
has, for a prominent symptom, the amenorrheic condition. Super- 
involution of the uterus, which is a rare condition, first described by 
Simpson, is at times a cause. 



126 Functional Diseases— Disorders of the Uterine Functions. 

Ar-ute peritonitis, followed by chronic pelvic peritonitis, leads to 
amenorrhoea, from local structural changes induced in the ovaries and 
tubes. 

The diagnosis of amenorrhoea is very easy, but the differentia of 
the varied conditions creating this symptom may require the most skil- 
ful diagnostician. 

The prognosis depends upon the cause. Most cases are amenable 
to treatment. Some are utterly incurable. 

The change of life, or the critical period of woman's life, is, 
"plrysiologically speaking, to the system at large of the elderly woman 
what the period of puberty is to that of the girl, or what the period of 
dentition is to that of the infant." It is not fraught with danger unless 
there is, or has been in former years, some serious local disease, which 
is very often the case. 

The Symptoms of the Menopause. — It is very common, previous 
to the menstrual cessation, that certain vague nervous symptoms are felt. 
The most common are what are called "hot flashes," a nervous phenom- 
enon, implying congestion of the nerve centers from any arrest of the 
flow, and relieved by a vicarious hemorrhage, as epistaxis (nose bleed), 
diarrhea, or leucorrhoea. The temper at times becomes irritable, and 
headaches, hysterical attacks, and unnatural fear, or sometimes melan- 
cholia, may be noticed. There are most usually changes in the phy- 
sique. The woman grows more fleshy, and often develops a growth of 
hair on the chin or face. Fat in the abdominal walls, simulating preg- 
nancy, is not uncommonly observed. Pruritis of the vulva and skin 
eruptions are not unusual. Sexual activity, where there was previous 
sexual frigidity, is not uncommon. 

Amenorrhoea is one of the functional types in young women and 
young girls arriving at the age in which we may hope for the greatest 
amount of good from the use of electricity. Both the galvanic and 
faradic currents may be used alternately, or simultaneously, in this 
condition. In addition, however, while the electricity is being daily 
applied, or on alternate days, tonics, good food, and proper exercise are 
prescribed to suit each individual case. I have frequently seen chronic 
cases of amenorrhoea yield satisfactorily to the galvanic current of elec- 
tricity after all other means have failed. If the amenorrhoea is due to 
chlorosis or struma, tonics of iron and cod-liver oil, raw eggs, and fresh 
milk, out-of-door exercise, good ventilation, and pleasant surroundings 
are of vital importance. So also is general faradization of the spinal 
vertebra ; applying the positive pole over the nape of the neck and the 
negative over the epigastric region, turn on the faradic current slowly 
and very carefully, gradually increasing the strength until the patient 
can feel it gently over the epigastric region; it must not be given 
too strong ; let it remain five minutes or more. Next place the positive 
pole between the shoulders over the vertebrae, holding the negative pole 
in the left hand from three to iive minutes ; then change the negative 



Functional Diseases — Disorders of the Uterine Functions. 127 

pole to the right hand and give the same length of time, just strong 
enough to be plainly felt is all that is necessary. As the next movement 
of the poles, place the positive pole over the lumbar region on the left 
side of the spine, but well up against the spine, and the negative pole 
over the sole of the left foot, giving it the same strength and time that 
you gave the hand. Lastly, place the positive pole up against the spine 
on the right side over the lumbar region, and the negative over the sole 
of the right foot ; give it from five to seven minutes, or from three to five 
minutes. On alternate days an electric brush may be used for general 
stimulation. 

In case of amenorrhoea due to sudden cold, fright, or shock, place 
the positive pole over the nape of the neck, the patient lying on her side, 
and the wire brush attached to the negative pole ; turn on the current 
gently, increasing it in strength until very perceptible to the patient, 
and apply the brush over the spine, and then all over the back, across 
the shoulders, down the sides, and over the hip- joints, keeping the 
brush all the while in contact with the skin, and also keeping the brush 
moving constantly over the back and spine, for about seven to ten min- 
utes. Then the positive pole may be placed over the lumbar region, and 
the wire brush used over the right and left legs for five minutes each; 
also stroke the feet with the brush for two or three minutes. Next 
place the positive pole between the shoulders, and stroke each arm with 
the brush, also the chest and abdomen, from five to seven minutes. It 
will take thirty-five minutes for a general faradic treatment with the 
brush. The patient must be kept covered during the entire seance, 
exposing only the parts of the body to be treated at the time, in order 
to avoid cold. Give the constant current also three times a week, alter- 
nating with the faradic current in cases of amenorrhoea being due to 
cold, fright, or shock. The positive pole, or anode, is placed over the 
nape of the neck, and the negative pole, or cathode, is placed over the 
end of the spine ; give from five to seven minutes, from thirty to fifty 
milliamperes ; move the positive pole over the dorsal vertebrae, and the 
negative over the left ovary, and give from thirty to forty milliamperes, 
for five minutes; move the negative pole over the right ovary, letting 
the positive remain over the dorsal vertebrae, and give it the same time 
and strength as the left ovary was given. Next, move the positive pole 
over the lumbar vertebrae, about the waist-line, and place the negative 
over the hypogastric region, just above the pubes, over the fundus or 
body of the uterus, and give the current simultaneously, that is, both the 
galvanic and faradic at the same time as strong as the patient can bear 
without pain or discomfort, and give from seven to ten minutes. Lastly, 
exchange the negative flat electrode for a uterine one, either of plat- 
inum, copper, zinc, carbon, or aluminum, place it in the cervex-uteri, 
and the positive over the end of the spine, give this also simultaneously 
for five minutes as strong as the patient can bear without pain. 
Usually I give about ten to twenty milliamperes with the faradic cur- 
rent, which is felt by the patient more than the galvanic current ; hence, 



128 Functional Diseases — Disorders of the Uterine Functions. 

the milliampere meter is our guide for the desired strength, the f aradic 
being the excitant current. This ends the seance. 

In addition to the treatment of amenorrhea due to cold, fright, 
shock, grief, or great anxiety, by the means of electricity, I prescribe 
tonics, laxatives, exercise, and cheerful company; also some kind of 
pleasant occupation to divert the patient's mind from her present condi- 
tion. I have found aloes and myrrh pills the most efficacious laxative. 
The dose, one pill night and morning, occasionally one at bedtime, is 
sufficient. The pills are to be taken regularly every night until the 
amenorrhea is overcome. The tonics are elixir of iron, quinine, and 
str^chnie, a teaspoonful after meals, in a wine-glass of water, three 
times a day. The above plan of treatment of amenorrhea, due to causes 
mentioned, has proven satisfactory in the writer's hands. 

In cases of amenorrhea due to an impoverished condition of the 
blood, from struma, chlorosis, or overwork, the f aradic current should be 
applied for half an hour daily, or every other day, for the tonic effect ; 
and in addition the patient should have plenty of rest, good food, and 
an abundance of fresh air and sunshine, and kind attention (there must 
not be any harsh treatment), tonics of iron, arsenic, and cod-liver oil, 
port wine and raw egg twice a day, dry climate, quinine for malaria, 
mercurials and iodides in syphilitic cases, which I have found to be the 
most effectual method of treatment for such cases. 

Amenorrhea due to acute diseases is overcome by such means, 
dietetic, hygienic, and medicinal, as will restore the general health. A 
nutritious and well-regulated diet, fresh air, and moderate exercise, 
with medicinal tonics, are called for. When the special diseases are 
cured, menstruation will in due time return. A progressive decline of 
the general health from chronic tubercular disease is evidenced by 
.menstrual cessation, so reappearance of menstruation may be regarded 
as a favorable prognostic symptom. ~No special attention is to be 
given this pelvic symptom, but the whole treatment is directed to the 
pulmonary lesion. The conditions call for a warm, high, dry climate, 
with plenty of outdoor exercise, nutritious food, cod-liver oil — the pure 
Norwegian oil is considered to be the best — tonics, and the galvanic 
current of electricity given through the lungs and bronchials, also the 
throat and tonsils if they are affected with tuberculosis. Place under- 
neath the left shoulder-blade a flat zinc electrode one and a half by three 
inches in length, covered with several thicknesses of surgeon's lint, wet 
in warm water with a little salt in it, it being made positive, and place 
the negative electrode of zinc, the same width and length, covered with 
lint in the same way, over the upper lobe of the left lung, and give 
from thirty to sixty milli amperes; in some cases patients can take 
eighty or more milliamperes. Give ten minutes ; then move the posi- 
tive^ electrode over the middle lobe of the left lung ; give it seven min- 
utes, with the same number of milliamperes as above mentioned. E"ext 
place the negative pole over the lower lobe of the lung, and let the posi- 
tive remain underneath the scapula ; give five minutes, and if the cur- 



Functional Diseases — Disorders of the Uterine Functions. 129 

rent feels comfortable to the patient, give seven to ten minutes; give 
from fifty to eighty milliamperes. Treat the right side in the same 
manner as the left. Next place the positive pole between the upper 
part of the scapulas or shoulders, over the spine, and the negative over 
the thorax; give fifty milliamperes for ten minutes. This ends the 
seance. On alternate days, treat the throat. Place the anode, or 
positive flat electrode, well covered with surgeon's lint, and wet with 
warm water with a little salt in it, over the left side of the spine, just 
below the nape of the neck, and place the negative round-sponge elec- 
trode, with handle, covered with surgeon's lint, wet in warm salt water 
(not too much water), over the left side of the throat; give from thirty 
to fifty milliamperes. Some cases can not take over twenty milli- 
amperes. When this is the case, it is usually due to a recent cold. 
Then the poles may be reversed, the positive placed over the throat 
and the negative over the left side of the spine, to relieve the con- 
gested condition of the throat, as the current flows from the posi- 
tive to the negative pole ; give ten minutes. Treat the right side of the 
throat the same as the left side. Next move the negative pole between 
the scapulas over the spine, and the round positive electrode over the 
bifurcation of the trachea, or hollow of the neck, and give from thirty to 
forty milliamperes, for ten or more minutes. When the throat is very 
irritable from a recent cold, I have often given twenty minutes over the 
bifurcation of the trachea in one seance, giving quick relief from an 
irritable cough. As the next move, with the two round electrodes cov- 
ered with lint, place the poles over the tonsils ; the positive should be 
placed over the most irritable tonsil, and give from twenty to thirty 
milliamperes, for ten or fifteen minutes ; this ends the throat treatment 
in consumptive cases. However, in cases of tuberculosis of the tonsils 
the tonsils may be cocained with a fifteen per cent solution, using care 
that the patient does not swallow any of the cocaine. The galvanic 
current of electricity may be beneficially applied by placing the positive 
pole over the tonsil internally, the electrode being of suitable size, of 
carbon, or aluminum, covered with absorbent cotton, dipped in per- 
oxide of hydrogen, and externally place the negative round electrode 
over the tonsil, corresponding with the inside positive pole, holding the 
tongue down with the left index finger, with a bit of absorbent cotton 
wrapped about the finger, which absorbs the saliva while the current is 
being given; give from ten to fifteen milliamperes, for five minutes. 
Treat each tonsil the same. 

Amenorrhoea due to plethora is said to be an indication for the 
use of belladonna. For obesity a dietetic management with abundance 
of exercise, and the f aradic current of electricity, has yielded the most 
excellent results in the writer's hands. First of all, the patient must 
be interested in her own case; otherwise she will not carry out the 
physician's directions as to diet. The following prescribed diet list 
for obesity I have found to be very excellent: She may eat freely of 
meat, poultry, game, fish, eggs, oil, cream, butter, cheese, gelatine, nuts, 



130 Functional Diseases — Disorders of the Uterine Functions. 

spinach, asparagus, celery, oyster-plant, onions, cucumbers, sea-kale, 
radishes, sorrel, olives, water-cress, tomatoes, cabbage, sprouts, cauli- 
flower, dandelions, mushrooms, beet-tops, turnip-tops, string-beans, 
plums, apricots, apples, gooseberries, watermelons. 

Eat sparingly of squash, pumpkins, currants, strawberries, pine- 
apples, sour cherries, sour oranges, muskmelons. 

Eat very sparingly of parsnips, carrots, beets, yellow turnips, 
cherries, sweet apples, peaches, sweet oranges, prunes, figs, and dates. 

Eat none of the following: Peas, beans, rice, corn-starch, sago, 
tapioca, macaroni, barley, corn (bread may be very brown-toasted, as 
zwieback), mush, potatoes, grapes, raisins, bananas, cake, pie, pudding, 
jellies, honey, ice-cream, preserves, sugar, molasses. 

Of drink or beverages, all alkaline mineral waters, tea unsweet- 
ened; coffee may be sweetened with saccharine only; chocolate and 
cocoa when the starch is removed, and skim milk. Milk and all malt 
liquors and sweet drinks are especially forbidden. 

The patient may drink freely of water after meals, but should 
drink slowly, as a too rapid drinking will overtax the stomach, as much 
as the half-masticated and hurried manner of eating interferes with 
digestion. 

Eor the reduction of fat, that unfortunate theory, "Eat what you 
please, but drink nothing," is based upon the theory that water, the 
greatest dissolvent known, carries with it throughout the entire sys- 
tem the particles of nourishment that would otherwise remain packed 
in the intestines. 

Great danger may arise from these accumulations being retained 
longer in the system than nature intended they should be, for the 
re-absorption into the system of poisonous matter is the cause of many 
' serious complications.. 

All agree that the application of water to the outward surface is 
essential for health, and that the supply should be generous and fre- 
quent ; yet many will deny the greater necessity of the internal wash- 
ing of canals which have not the advantage of either air or sun for their 
purification. 

Nearly all hearty eaters are troubled with constipation or too closely 
compacted faecal matter, but drinking plentifully of pure water, and 
copiously flushing the intestines with warm water with a teaspoonful 
or two of salt added to it, once every three or four days, will give great 
relief in such cases. However, I have known of patients who were not 
plethoric flushing the bowels daily, to their injury; hence, too much 
flushing of the intestines should be guarded against. The faradic cur r 
rent of electricity should be given through the central nervous system, 
through the liver, and over the stomach and abdomen, down the spine, 
and from the sacral region down to the soles of the feet, and from the 
cervical vertebra to the palms of the hands, once every day for three 
months, then twice a week, and then once a week for two or three more 



Functional Diseases — Disorders of the Uterine Functions. 131 

months until the patient's obesity is overcome. The patient can be 
taught to treat herself with a faradic current of electricity. 

Massage is very useful in reducing obesity. Turkish baths, which 
may be taken once a week, are very beneficial in some cases where there 
is no heart trouble. 

Eheumatic amenorrhoea calls for the salicylates. Physiological 
experimentation with the salicylates shows that they stimulate the 
menstrual secretion, as well as the hepatic secretions. Give five grains 
every six hours, in milk, both day and night, until rheumatism is 
relieved. Cimicifuga is a beneficial remedy for rheumatic amen- 
orrhoea, and especially for delayed and painful menstruation. Guai- 
acum is an old-time remedy under similar circumstances. Strychnine 
and iron is a good muscle and nerve tonic. Pulsatilla, is indicated 
where there is mental shock or fright. Apiol is an efficient emena- 
gogue ; it may be given in capsules of five drops for a dose, two or three 
times a day, for a week preceding the flow. Electricity, the galvanic 
current, is par excellence for all rheumatics complicated with amen- 
orrhoea. The anode flat zinc electrode placed over the seat of pain, 
and the cathode placed on the thigh or on the sole of the foot or in the 
palm of the hand, and given twenty to thirty minutes, and from fifty 
to one hundred milliamperes, will relieve the rheumatism. Where 
there are several seats of soreness and pain, place the anode, or positive 
electrode, over each affected part, and the negative below at some point 
on the lower extremities or sole of the foot, or palms of the hands ; give 
each affected part ten minutes or more, according to the acuteness of 
the case ; give from fifty to one hundred milliamperes. If the case is 
chronic, electricity should be given every other day until the patient is 
relieved of rheumatism. Acute cases should have daily seances. 

Caulophyllum, aletris-farinosa, and polygonum-hydropiperoides 
have been recommended for the amenorrhoeic condition. 

The hygiene of all amenorrhoeic patients needs most careful look- 
ing after. A good, nutritious diet, an abundance of fresh air, out- 
door exercise, and cold shower baths are never to be neglected. Sea 
bathing is almost always useful. A change of place is often highly 
beneficial, particularly from inland to the seaside. Marriage, too, is 
at times to be considered. 

The uterine functions should not be forced, when the general sys- 
tem is struggling for existence. Very few remedies have any direct 
stimulating effect on the lining membrane of the uterus. Some of 
them, when, given in large doses, cause the expulsion of the uterine 
contents, by stimulating its muscular fibers to contract. 

Hot hip-bath and foot-bath are useless unless the function is about 
to appear. 

Acute suppression should be treated by rest in bed, local warmth, 
and hot drinks, with half-grain doses of calomel with a grain of soda, 
an hour apart, until three doses have been taken; and in eight hours 
after the last dose has been administered, take a heaping teaspoonful 



132 Functional Diseases — Disorders of the Uterine Functions. 

of Epsom salts in a half tumblerful of warm water, to move the bowels 
freely, and to relieve the general congested condition of the system. 
Iron stands first as a tonic, because of its haematic tonic action, increas- 
ing the blood supply of the pelvic organs. When the stomach is ready 
to receive tonic doses of iron, the dry sulphate, the carbonate, the 
muriated tincture, or the syrup of the iodide of iron may be chosen. 
The iron should be given with nux-vomica and quinine. 
The following pill is considered sufficient : — 

1£: Ferri sulphatis exsiccati B ij 

i Quinse sulphatis B ij 

Strychniee sulphatis gr. i 

Extracti gentianse q. s. 

Misce et fiat in pill or capsule, XL. 
Sig.: One pill after each meal. 

Blaud's pill may be given. Glide's Pepto-mangan is an excellent 
preparation of iron. Wyeth's preparation of manganese and iron, 
given in dessert-spoonful doses, in milk or water, after meals, three times 
a day, is a valuable remedy in all cases and conditions of this class. 

The potassium permanganate and the bin-oxide of manganese are 
new remedies added to our list of emenagogues. Experience has 
shown that they are valuable remedies, administered for a few days 
or weeks preceding menstruation, in doses of one to two grains, three 
times a day. The best form for their administration is in compressed 
tablets, or in a gelatine-coated pill. 

Electricity is the most reliable of all the emenagogues, being the most 
direct uterine stimulant that we possess. The galvanic and faradic 
currents may be used on alternate days, keeping in mind that the cur- 
rent flows from the anode, or positive pole, to the cathode, or negative 
pole. The primary current of the faradic should be used first. The 
negative pole is placed in the uterus, and the positive pole is applied 
externally over the body of the uterus, as strong a current as the patient 
can bear with comfort, a seance of fifteen minutes. Then place the 
positive electrode over the sacral region, and the negative on the inside 
of the thigh, and give a seance of five minutes. Treat the opposite 
thigh likewise. On alternate days use a mild galvanic current or a low 
amperage ; place the positive pole over the left side of the spine, about 
the waist line, the negative placed over the left ovary; give twenty to 
thirty milliamperes, for jive minutes. Treat the right side the same 
as the left ; then move the positive pole over the body of the uterus, 
externally, with the negative placed in the uterus, and give -five to ten 
milliamperes for jive minutes. This treatment should be kept up until 
the patient recovers from acute suppression. 

In uteri that are small and ill-developed, or atrophied from super- 
involution or chronic metritis, or in cases where the internal genitalia 
are markedly dormant and atonic, the local use of electricity is the 
most efficient method of cure. Personally I can number many cases 



Functional Diseases — Disorders of the Uterine Functions. 133 

which I have treated for sterility, and fertility has resulted from 
thorough electrical treatments. 

If there is atresia of the vagina or uterus, the treatment is surgical. 
When the occlusion is low down ; from an imperforate hymen, or in the 
vagina above the hymen, a free crucial incision, with thorough anti- 
septic drainage, is needed. This class of work should be performed by a 
gynaecologist. 

Vicarious menstruation is a condition closely allied to amenorrhoea. 
It means a condition of the female system in which there is a regularly- 
returning discharge of blood from other parts of the body besides the 
uterus. This vicarious sanguinous flow comes from the nose, the 
bronchial tubes, the stomach, the intestines, or the rectum. The writer 
had one case of a young school-girl sixteen years of age, who had vicari- 
ous sanguinous flow from the mammaes regularly every month. The 
natural monthly flow ceased when the vicarious flow from the breasts 
appeared. To all appearances, the patient was in good health; she 
had no pain, and performed her school work daily without any undue 
symptoms of overwork. Iron and cod-liver oil was prescribed, and the 
f aradic primary current of electricity was applied three times a week. 
The anode was placed over the left mammae, and the cathode placed 
within the vagina by an appropriate vaginal electrode, it being carried 
well up into the left cul-de-sac, between the uterus and the vaginal 
wall, as near the ovary as possible, and the current given as strong as 
the patient could tolerate ; the seance was given ten minutes. The 
right mammae and ovary were treated the same as the left ; then the 
anode was placed over the sacrum, and the cathode in the rectum; 
seance ten minutes. The patient recovered underlie treatment. 

A vicarious sanguinous flow comes from the nose, the bronchial 
tubes, the stomach, etc. Good tonics of iron, quinine, and strychniae 
(Wyeth's Elixir is an efficient tonic), and the galvanic and f aradic 
current applied alternately, as prescribed in amenorrhoea, are very 
valuable in such cases. A change Of climate is beneficial, and a good, 
nutritious diet, exercise, cheerful company, and pleasant surroundings 
are needful in such cases. 

MENORRHAGIA AND METRORRHAGIA. 

Menorrhagia is an excessive menstrual flow, the opposite of 
amenorrhoea. There are menorrhagic conditions as to time, quantity, 
and duration, as well as an absolute menorrhagia. Thus, if menstrua- 
tion appears too frequently, is excessive in quantity, or continues too 
long, the condition is menorrhagic. 

Metrorrhagia means non-menstrual uterine hemorrhage. 

Etiology. — Both menorrhagia and metrorrhagia are generally 
dependent upon a common cause, and both usually exist at the same 
time. They depend upon many and widely different causes, both 
constitutional and local. 



134 Functional Diseases — Disorders of the Uterine Functions. 

The constitutional causes are plethora, anaemia, and chlorosis, 
debility from lactation, haemophilia, puerpura, scorbutis, chronic valvu- 
lar disease of the heart, chronic pulmonary diseases, as pneumonia 
and emphysema, hepatic disease, constipation, and abdominal tumors, 
and physical influences. 

The local and pelvic causes are, local and peri-uterine congestion 
and inflammations, tubal inflammatory diseases, hsemato-salpinx, uter- 
ine congestion, chronic metritis, sub-involution of the uterus, chronic 
endometritis, fungoid granulations, cervical lacerations, uterine dis- 
placement, especially retroversions and retroflexions, uterine fibroids 
and polypi, cancer of the uterus, and the retention of the products of 
conception. 

Uterine and ovarian congestion, followed by menorrhagia, may be 
provoked by excessive coitus. Menorrhagia occasionally from plethora. 
Stout, obese women generally have scant menstruation. 

Any cause which eventually alters the quantity or deranges the 
quality of the blood, as plethora, anemia, chlorosis, or hematocele, may 
lead to excessive menstruation. 

Any cause which impedes the normal return of the venous blood, 
as valvular disease of the heart, chronic pneumonia, or emphysema, 
hepatic, splenic, and renal diseases, abdominal tumors, or loaded 
bowels, are almost always attended by prolonged and profuse menstrua- 
tion. Physical causes also act in the same way. Fright, fear, and 
excessive mental or emotional disturbances act as potently as do 
morbid physical conditions. 

One of the most common causes is the presence of fungosities 
within the uterine «avity, either from chronic endometritis or from a 
retention of some of the products of conception. The profuseness of a 
menorrhagic attack is by no means in proportion to the size of an intra- 
uterine growth; a small polypus and fungosity may act as potently as 
large tumors. 

Malignant disease of the uterus is almost invariably accompanied 
by menorrhagia and metrorrhagia. These are its first symptoms, and 
they are diminished only late in its progress. Many women become so 
accustomed to losing blood per vaginam that any beginning hemorrhage 
may be neglected. Many women labor under the impression that the 
change of life must be attended by an excessive menstrual flow. The 
cause of any excessive menstruation should always be sought, as this is 
invariably indicative of some disease. 

Laceration of the cervix uteri is a very common cause of cervical 
erosion, eversion, and a general endometritis, with fungoid granulations, 
hence menorrhagia results. Parametritis and perimetritis have metor- 
rhagic as common symptoms. In all uterine displacements and flexions, 
the uterus is the seat of more or less hyperemia from an impeded venous 
circulation. 

Of the various displacements, retroversion is most commonly so 
attended. 



Functional Diseases — Disorders of the Uterine Functions. 135 

Sub-involution of the uterus, in which the organ is enlarged, soft- 
ened, imperfectly contracted, and congested, has monorrhagia for a 
symptom. Sub-involution is often the first stage of chronic metritis. 
The second stage of chronic metritis is also attended by excessive men- 
struation, and the menorrhagia does not cease until the third stage, or 
cirrhosis of the uterus, has commenced. 

Treatment. — Kest in bed for the attack is the first consideration. 
In the recumbent position of the body, the pelvic organs, whether the 
seat of active or passive hyperemia, are, through the influence of grav- 
ity, relieved to no inconsiderable extent of an increased blood supply. 
All tight clothing ought to be removed. The bed should be cool and 
not too soft. The food should be light and non-stimulating. Keep the 
bowels open and the rectum and the colon unloaded, and favor the 
return of the portal venous circulation, which is intimately connected 
with the pelvic. Occasionally one-fourth of a grain of calomel should 
be given every hour until four doses are administered; in eight hours 
after the last dose of calomel, take a saline mixture of sulphate of 
magnesia or Epsom salts — not too large a dose ; a heaping teaspoonful 
usually moves the bowels two or three times; should it not do so, the 
salts must be repeated. After this an occasional cholagogue, followed 
by a saline mixture, as salts, may be administered with advantage, to 
keep the colon unloaded. An enema of warm water with a little salt 
added to it is advisable when the bowels do not move themselves ; or a 
tablespoonful of glycerine in one pint of warm water injected into the 
bowels, and retained for a short time, is very effective in unloading the 
colon. 

Chronic constipation may be overcome by mild salines, magnesia 
sulphate, Kochelle salts, cascara sagrada, small doses of podophyllin 
with nux vomica, or Wyeth's triturate for mild laxative. Black coffee 
taken upon rising early in the morning, on an empty stomach, is a most 
efficient laxative. One heaping tablespoonful of black coffee to one 
teacup of boiling water ; let it steep for ten minutes on the back of the 
stove ; must not boil ; sip it very slowly, swallowing air with each sip of 
coffee, and it will usually move the bowels in half an hour. The air 
can best be swallowed with the small sips of coffee when the patient is 
in a recumbent position. The writer has used black coffee, as above 
described, for many years, for constipation, without ever having to 
resort to any other means. Neither milk nor sugar must be added to 
the coffee. The hot coffee stimulates the nervous system to quick 
action, also keeping the mind on what you are about. Psychic 
influence seems also to help; for if the mind is diverted from the 
object to be attained, the wind swallowed will return and escape by 
the mouth, when it will not do so if the mind is full upon the object in: 
view, but will pass off through the natural channel, carrying with it 
the pent-up faecal matter, down into the rectum. 

The best medicinal haemostatics will depend entirely upon the 
provoking causes. Should the fault lie in the heart's action, or in 



136 Functional Diseases — Disorders of the Uterine Functions. 

retarded venous blood circulation, one of the best medicines is digitalis. 
A good tincture made from the English leaves, or a pure infusion, is 
said to be the best form. The writer has found Wyeth's heart tonic 
and stimulant to be very efficacious to overcome retarded venous circu- 
lation in these conditions, one triturate, taken three times a day, until 
the circulation is in a normal condition. 

Morbid physical conditions are best relieved by the bromides. 
Bromide of sodium is one of the most useful. Chloral hydrate and 
bromide of sodium are very useful in promoting quiet and sleep. 

ft: Chloral hydrate 3 ij 

Sodium bromide , 3 iv 

Aqua menth pip E vi 

M. et fiat. 

Sig. : Teaspoonf ul every three or four hours during the day, in a 
wine-glass of water. 

To promote sleep, it may be taken every two hours; usually two 
doses have the desired effect. Menorrhagia from excessive coitus also 
calls for bromides, also hot vaginal douches every six hours, with rest 
in bed, until the monorrhagia is overcome. 

Faulty conditions of the blood from anemia, chlorosis, excessive 
lactation, haemophilia, or defective hygiene, are best improved by a 
good hygiene, weaning of the child, and internal administration of 
iron and other tonics. As a rule, iron is contra-indicated during 
menstruation, especially if the flow is excessive, but to this rule, as to 
others, there are exceptions. Iron in the form of muriated tincture 
proves to be an excellent means for checking excessive menstruation 
dependent on marked anaemia, hydraemia, and haemophilia. In most 
cases the iron is to be given only during the menstrual interval. 

Menorrhagia from plethora demands a restricted diet, and the use 
of the salines and the bromides. Take Rochelle and Epsom salts, equal 
parts, a heaping tablespoonf ul every morning in a half tumbler of warm 
water. A little lemon may be added to make it more palatable. 

Arsenic is a most valuable haemostatic in the menorrhagic condi- 
tion of young girls, as well as of women nearing the menopause. 
Menstruation, which at either time of life comes on too frequently, 
continues too long, or is too profuse, being purely functional, is best 
met by Eowler's solution of arsenic. Doses, from two to three drops, 
three times a day, after meals. It seems to be indicated when iron is 
contra-indicated, and may be given during the interval. Hydrastis 
canadensis has been an efficient remedy in the writer's hands, given in 
half-dram doses between the regular periods of the flow. During 
the regular period, ergot may be used, combined with the hydrastis, 
equal parts. Give half a dram three or four times a day. The 
hydrastis may be given for months ; may be taken in a little water, half 
an hour before meals. Twenty-five or thirty drops is an ordinary 
dose. 



Functional Diseases — Disorders of the Uterine Functions. 137 

Ergot stands at the head of the list of all medicines as a uterine 
haemostatic, because of its stimulating effect in contractions of the 
involuntary unstriated muscular fibers, wherever found. The more 
soft, flabby, relaxed, and engorged with blood the uterus is, the 
more pronounced will be the good effects of ergot. 

Quinine is the remedy when the disease is malarial in origin. 
Ergot may be combined with the quinine for malaria. ^Tux vomica 
increases the action of ergot, hence small doses may be combined with 
the ergot and quinine. 

Hamamelis is one of several useful remedies ; it is taken internally 
in the form of the fluid extract. It is an American remedy, and has 
been utilized for hemorrhages from all parts of the body, and for vari- 
cose veins, haemorrhoids, and for any slow or long-continued flux ; when 
the blood is dark and venous, and the hemorrhage is passive in char- 
acter, it is the remedy par excellence. 

For flabby, enlarged, sub-involuted uteri, after delivery at term, 
and after abortions, also in some forms of chronic endometritis before 
or following the removal of fungosities, and in chronic retroversion, 
viburnum prunifolium combined with hydrastis canadensis, equal 
parts, should be given in doses of half to a teaspoonful, between meals, 
in a wine-glass of water, three times a day. Cannabis indica is highly 
recommended by some writers. 

For the hypodermic use of hydrastinin, a ten-per-cent solution may 
be given hypodermically. Use Lloyd & Brother's, Cincinnati, called 
"Lloyd's Specific Medication." 

The action of all medical agents should be enhanced in bad cases 
by local applications. Cloths wrung out of hot water, or a rubber bag 
filled with ice-water or pounded ice, may be applied over the hypogas- 
tric region, having one or two thicknesses of flannel laid over the hypo- 
gastric region, and the ice-bag on top of this to prevent freezing of the 
skin. The writer prefers heat. Use very hot vaginal douches, as hot 
as can be borne on the back of the hand ; this is a quick and efficient test 
when there is no thermometer at hand. Elevate the hips; from one 
to two or even three gallons may be given every six hours. While the 
hot douche is being administered, add enough hot water to what is 
being given, to keep up a steady heat, being careful not to have it too 
hot, as it would injure the vaginal walls. The temperature of the 
water may be 125 degrees or even 130 degrees Fahrenheit. A salt solu- 
tion of warm water, one pint of warm water with one level teaspoonful 
of salt added to it, may be injected slowly into the rectum in cases where 
the patient is profoundly anaemic from the loss of blood. This is a 
most excellent way to revive a swooning patient, thereby stopping the 
flow, and sustaining her by the absorption of the saline fluid. In 
emergency cases place vaginal tampons, made of absorbent cotton dipped 
in glycerite of alum, against the os uteri after the douche. Almost all 
families have alum at hand. Dissolve a teaspoonful in a teacup of 
boiling water, let it cool down to about the same heat as for a vaginal 



138 Functional Diseases — Disorders of the Uterine Functions. 

douche, dip the tampon of cotton in the alum, and pack it around the 
uterus, filling the vagina; this will usually check severe hemorrhage. 
If you have no medicated cotton at hand, use small strips of an old 
linen handkerchief, previously dipped in boiling water, then dipped 
into the alum water, pack it well up against the os uteri, and fill the 
vaginal vault with strips of old linen dipped in the alum solution ; this 
should be done immediately after giving the hot vaginal douche. The 
packing should not be removed for seven or eight hours, when it may be 
removed and another hot douche given, and dry absorbent cotton, 
sprinkled over with a little tannin and iodoform, should be packed 
firmly about the os uteri, filling the vaginal vault down to the outlet 
with pure absorbent cotton. Allow it to remain another eight hours; 
then repeat the douche, and packing also if necessary, daily, until the 
patient is relieved. Many authors recommend letting the dressing 
remain from twelve to twenty-four hours before removing it. Should 
this vaginal packing fail to check the hemorrhage, . the uterine cavity 
is to be packed with sterilized gauze, after the uterus is dilated with 
the metallic forceps and curetted. This dilatation and curettage is not 
to be neglected in many of these cases of chronic endometritis. 

The following principles expressed by Dr. Keating should ever 
be borne in mind, in the treatment of menorrhagia: "In all cases, if 
any local interference is needed, see that the uterine canal is kept open ; 
obtain and maintain a patulous uterine canal. This itself tends to 
arrest the bleeding. Then remove the foreign bodies, products of con- 
ception, fungoid granulations, intra-uterine polypoids, and fibroid 
tumors. During the intervals of menorrhagia, the judicious and thor- 
ough use of the intra-uterine curette is one of the best means of 
promptly and safely curing many of these cases. Its use should pre- 
cede any intra-uterine medication. The best local uterine medicaments 
are Churchill's tincture of iodine, iodized phenol, and iodo-tannin." 

These medicaments may be applied with a probe wrapped with 
cotton, or with the intra-uterine syringe. Intra-uterine injections are 
said to be safe, if the cervical canal is patulous, if the fluid is warm, if 
no air is injected, and if no force is employed. 

Cancer of the uterus calls for hysterectomy, partial or complete. 

Mal-positions of the uterus which give rise to menorrhagia are 
treated by replacing the uterus in its proper position by tampons, by 
electricity, or by pessaries. Coexisting chronic endometritis is to be 
treated by dilatation, curettage, and packing. Lacerations of the cer- 
vix and their sequelae call for curettage and trachelorrhaphy. 

In bad cases of uterine hemorrhage, dependent upon fibroids and 
chronic affections of the endometrium, local galvanization of the uterus 
is one of the most worthy therapeutic agents that we possess. It is 
best to use the curette a week before commencing the use of galvaniza- 
tion. The positive pole, with a suitable sterilized electrode of iridium 
or platinum, should always be applied within the uterus. The effect 
of the positive pole is to coagulate the albuminous particles in its 



Functional Diseases — Disorders of the Uterine Functions. 139 

immediate vicinity, and thereby produce a hardness of these tissues. 
This characteristic action varies, with the strength of the current, from 
slight congealing and hardening of the tissues to general coagulation 
and solidification for a considerable space around. Positive galvaniza- 
tion is a most potent haemostatic — a large flat electrode of pure tin or 
zinc, four by six inches, covered with eight or ten thicknesses of sur- 
geon's lint dipped in warm salt water, and placed over the abdomen 
(the electrode being negative), and a piece of oilcloth or oil-silk placed 
over the electrode, also a towel over the oil-silk to prevent wetting the 
patient's clothes. The patient may place one or both hands over the 
electrode to keep it firmly in contact with the skin, or a broad bandage 
may be drawn around the waist and over the electrode and fastened 
tight enough for comfort, yet it must not slip during the entire seance. 
The vagina should be washed with an antiseptic solution previous to 
placing the positive uterine electrode into the uterus. Give from 
forty to fifty milliamperes, from fifteen minutes to half an hour; 
the reverse current may then be given about one minute, giving only 
about twenty milliamperes, to loosen the positive electrode, which sticks 
to the uterine tissues or fibroids ; then the electrode can easily be 
removed. After each uterine treatment, wash out the vagina with an 
antiseptic solution. This treatment should be repeated every other 
day until hemorrhage ceases, and the tumor is reduced. If the 
hemorrhage is due to endometritis, not more than from twenty to forty 
milliamperes should be given in the endometrium or in the fundus of 
the uterus. The positive is placed in the uterus, and the large flat 
electrode over the abdomen. 

Chronic endometritis with hemorrhagic vegetations is very suc- 
cessfully treated with the galvanic current, the positive electrode being 
made active in the first stages of endometritis and metritis. In the 
third stage the negative electrode should be used in the uterus. The 
absorption of the hypertrophied tissue is stimulated by the inter-polar 
effect, while the polar effect is localized on the diseased endometrium 
and its immediate surroundings. The seances may be for fifteen min- 
utes, once in two or three days, giving from thirty to fifty milliamperes 
in some cases ; others require only from twenty to forty milliamperes. 

DYSMEXOEEHOEA. 

Dysmenorrhoea means difficult or obstructed menstruation, with 
pain preceding, accompanying, or following the menstrual discharge. 

A certain sense of pelvic fulness or a bloated feeling is usually 
expressed, and attends, more or less, the menstrual function; but as 
normal menstruation is not attended with any special pain, the painful 
menstrual period is called dysmenorrhoea. All chronic inflammatory 
pelvic diseases which are attended with pain at the menstrual interval, 
have more pain at the time of the flow, but this is not dysmenorrhoea. 
Neither are those cases instances of dysmenorrhoea in which inter- 



140 Functional Diseases — Disorders of the Uterine Functions. 

menstrual pain comes on with marked regularity about the middle of 
the inter-menstrual period. Dysmenorrhea is one of the most common 
of the various menstrual derangements, and manifests itself by pain, 
which varies greatly as to frequency, time, duration, and severity. As 
it stimulates other pelvic affections, they are sometimes taken for it, 
and vice versa. 

"Dysmenorrhea is properly divided into the following varieties: 
The neuralgic, the congestive, or inflammatory, the obstructive, and the 
membranous." We meet with all these forms in general practise, and 
they have symptoms more or less in common, but they are different in 
their morbid conditions. As a rule, the dividing line between the 
varieties is not well marked. Normal menstruation depends as largely 
on a good condition of the constitution at large as on a healthy state of 
the intra-pelvic organs. Hence dysmenorrhea may be constitutional 
or local in its origin. The variety known as ovarian differs from the 
others more in location than in kind. Spasmodic dysmenorrhea is a 
term applied to the neuralgic form in which there is a spasm of the 
circular fibers about the os internum. 

Neuralgic Dysmenorrhoea. — Neuralgic dysmenorrhea is a variety 
in which no special disease of the uterus or the appendages may be 
detected, except a tenderness on pressure; or in bimanual palpation 
there is usually found to be a tenderness in the ovarian region and 
along the tubes. Physical exploration often shows no alteration in 
size, shape, position, consistency, or vascularity of the pelvic organs; 
no structures will be noticed, or if any are noticed in any case, the mor- 
bid condition is quite uncertain as to location, quantity, or variety, no 
two cases being alike. The most severe types are seen in the nulliparae, 
in which there is no structural lesion of the uterus. The insertion of 
the uterine sound or an electrode into the interior of the uterus will 
elicit pain identical in kind and degree with the dysmenorrheic pain. 
A slight discharge of blood sometimes follows the use of the sound, 
even when very carefully done. The nerves of the endometrium are 
in a state of hyperesthesia, a neuralgic condition. This hyperesthesia 
is mostly of the internal os uteri. A fissured state of the neighboring 
endometrium, inducing a spasm, may at times excite a contraction such 
as we see in anal fissures, which are very painful. In such a state 
menstrual pain will be excited by the influx of the blood into the tis- 
sues. The greater the tension and the rigidity of these tissues, other 
things being equal, the greater the pain. A similar unyielding char- 
acter of the tissue is present in some cases of chronic metritis ; with it 
there is undue vascular tension and a compression of the end nerves, 
which are always irritable. When the flow is well established, the 
swelling subsides, and the tension is relieved. 

Causes of Neuralgic Dysmenorrhoea. — The constitutional condition 
must first be determined. A local neurotic state may, by the stimulus 
of the physiological pelvic congestion, be provoked to pain, incident to 
the oncoming menstruation. The pain is increased by the presence of 



Functional Diseases — Disorders of the Uterine Functions. 141 

the hemorrhagic flow within the uterine cavity. The local neurosis, 
an expression of the nervous system in which there is an exalted sensi- 
bility to pain, shows itself by general hysterical phenomena, spinal 
irritation, neurasthenia, and local and general neuralgia. Pain, like 
age, is relative. The causes may be the same, but no two patients suffer 
exactly alike. Anemic and chlorotic states of the blood always pre- 
dispose to neuralgic dysmenorrhea. 

Rheumatism and gout are direct exciting causes. The rheumatic 
dysmenorrhoea resembles neuralgic. All habits of the body conducive 
to indolence, want of proper physical exercise, and faulty methods of 
dress, by enervating the nervous system lead indirectly to dysmenor- 
rhoea. Hence, the disease is relatively more common among the upper 
classes. Excessive venery and masturbation favor its development. 
General ill health retards easy and physiological disintegration of the 
intra-uterine membrane. These diseases are too often due to a poor 
inheritance, a defective hygiene, a forced education, and the false 
stimulus of our modern and artificial life. 

Symptoms. — Every possible kind of pain may be experienced as 
io time, duration, location, and severity. Some cases are so pro- 
nounced that pain is felt at the very inception of the menstrual func- 
tion, and continues with an increasing force for years after, until it 
becomes very severe, most dreaded, spasmodic, and agonizing. In this 
neurotic variety the pain is intermittent, remittent, or continuous. 
Again, it may start after years of painless menstrual life; for instance, 
commencing after marriage. Severe types of the disease are often 
associated with reflex headaches, sympathetic nausea and vomiting, or 
neuralgic pains elsewhere, at the menstrual times, seemingly supple- 
menting or superseding the localized uterine pain. Other organs of 
the pelvis, as the bladder and rectum, become affected by sympathy. 
The breasts become tumid and tender. Sometimes there are periods 
of uncertain length during which there is little or no pain, after which 
there may be a relapse. Such periods are noticeable after physical 
or mental recreation, a change of habits, and during and after a time of 
traveling, with its manifold divertisements. 

* Severe dysmenorrhoeal attacks are always attended and followed 
by such prostration, so that weeks are needed for a full recuperation. 
The pain is felt and located in the ovarian regions, extending from 
either side down to the os uteri, as is usually described by patients, as 
traveling from the ovary low down in the vagina, and at other times 
across the lower hypogastric region about the fundus of the uterus. 
Often pain is felt in various parts of the body, and especially about the 
region of the heart. It comes on soon after the first commencement 
of the flow, is most severe during the first day, becomes less during the 
second day, and least toward the last. The discharge may be scanty or 
profuse, or may consist of clots. The pain in severity seems to be in 
inverse ratio to the quantity of the flow. The diminution of the flow 
is not so manifest in the neuralgic as in the congestive variety. Neu- 



142 Functional Diseases — Disorders of the Uterine Functions. 

ralgic dysmenorrhoea is by far the more common variety. Commenc- 
ing early in life, it is found more often in those who are subject to the 
various neurotic diseases. 

One of the most common pathological lesions in this variety is 
antiflexion of the uterus, or some defect of the uterus. The flexion 
itself does not cause the painful menstruation so much as it does when 
the uterus is antiflexed, and it may be because the uterus is ill-developed 
and neurotid. 

CONGESTIVE AND INFLAMMATORY DYSMENORRHOEA. 

* Pathology. — This variety having more distinct symptoms, any 
cause, constitutional or local, which promotes or perpetuates active or 
passive hypersemia of the uterus, may lead to it. The inflammatory 
types are of a chronic form, and may not only complicate the uterine 
tissues proper, but likewise involve the parametric structures, — tubal, 
ovarian, and peritoneal. 

Symptoms. — Pain is usually present for days prior to menstru- 
ation, increasing each day as that function approaches, and mitigating, 
more or less, after its appearance. The woman feels more at ease after 
the flow is established, contrary to the neurotic variety. 

The diagnosis is based on the symptomatology, and on the signs 
found on physical examination. 

Ovarian dysmenorrhoea implies ovarian congestion or inflam- 
mation. Some defective development of these organs predisposes to 
neuralgia, or a varicocele of the pompiniform plexus of the organ if 
present. Scanzoni suggested that the ovarian pain may be due to the 
maturing of a graafian vesicle lying deep in the ovarian stroma. 

OBSTRUCTED DYSMENORRHOEA. 

The essential condition of this variety of dysmenorrhoea is a reten- 
tion of the menstrual secretion. " Abnormities of the uterine cervix, 
congenital and acquired, with stenosis, are by no means uncommon. 
Of the congenital form there is especially the elongated and the conoid 
infra-vaginal cervix, with the pin-hole os of the acquired; that which 
arises from chronic inflammation of any of the tissues, and especially 
that which results from the vicious use of certain caustics. This sten- 
osis is sometimes very great, and there may be almost complete occlu- 
sion. Flexions of the uterus can create obstruction only when they 
are sharp, and the curvature is present to the second degree. Dys- 
menorrhoea associated with antiflexion does not come from any obstruc- 
tion of the canal." (Palmer, M. D.) 

Some standard as to the size of the cervical canal is usually 
accepted. Tilt has said, "When the cervical canal will not allow an 
ordinary sound to pass through it easily, it ought to be dilated or 
divided." Sims denied that the easy passage of a medium sound into 
the cavity is proof that there is no need of surgical interference. But 
the size of the canal, like the menstrual flow in quantity, is relative and 



Functional Diseases — Disorders of the Uterine Functions. 143 

not absolute. The best evidence of obstruction is obtained when the 
withdrawal of the sound is followed by the pent-up secretion or blood. 
Besides this, there are narrowings and tortuosities of the uterine canal 
from the presence of intra-uterine and interstitial fibroids. Mem- 
branous dysmenorrhoea is clearly due to impeded menstrual flux, for 
as soon as the false membrane is expelled, the pain is relieved, and the 
uterus is at rest. All these circumstances, — the seat and kind of pain, 
intermittent, expulsive, and resembling labor, and the duration and the 
intermission of the flow, — may be more or less characteristic. Such 
pain is called expulsive, for the uterus is struggling to overcome a 
resistance, also to expel its contents. 

It is not difficult, in a certain sense, to understand how all the 
varieties of dysmenorrhoea (but not all cases) may at times be 
attended with a certain narrowing of the channel of the uterus or 
uterine canal, — the neuralgic by a spasm of the circular fibers, espe- 
cially at the internal sphincter of the cervix ; the congestive dysmenor- 
rhoea by a swollen endometrium, clots of blood, and broken-down 
mucous membrane ; and the membranous by its false membrane. That 
the oft-repeated attacks may lead to structural changes, is well under- 
stood. The neuralgic dysmenorrhoea may lead to congestive. All dys- 
menorrhoea should not be regarded as obstructive, and for this reason 
"there is a want of conformity between the seeming causative lesion, or 
abnormity, and the symptoms." 

Not only, as stated, may there be dysmenorrhoea when no abnormal 
conditions of the uterus as to size, shape, condition, or position can be 
detected, but, on the other hand, well-defined abnormities of the uterus, 
as the pin-hole os, the elongated cervix, the contracted canal, the flat- 
tened and ill-developed uterine body, and flexions, may be present, and 
there may be no dysmenorrhoea. 

Associated with organic diseases or not, sometimes developed but 
more often aggravated by them, clinical evidence points to the con- 
clusion that neurotic features are the only ones in many cases, and they 
are manifest more or less in all. 

MEMBRANOUS DYSMENORRHOEA. 

Pathology. — "This variety, the least common, consists in casting 
off, in shreds or in complete sections, of the superficial layer of the 
uterine mucous membranes. The cast-off film resembles a product of 
conception, and its expulsion has been mistaken for an early abortion. 
It is soft, comparatively thick, with many perforations, the sites of the 
utricular follicles. It is the lining membrane of the uterus, hyper- 
trophied in all its structures, as in pregnancy, hence called the men- 
strual decidua. But the absence of the chorionic villa and the decidual 
cells, proves that it is not a product of pregnancy." 

Two views in the main are held : That its production is the result 
of some ovarian disease (Tilt and Olshausen) ; that it is a desquamation 



144 Functional Diseases — Disorders of the Uterine Functions. 

or exfoliation of the uterine mucous membrane (Raciborski and Simp- 
son.) Klob, whose opinions are widely accepted, says, "It is an 
exudation from endometritis." Braum also accepts this view. 

Symptoms. — The dysmenorrhoeic pain begins at the inception of 
the flow, and increases in severity until the sac is completely expelled. 
The pain resembles those of an early abortion or the first stage of 
parturition. The menstrual flow increases in quantity until the 
expulsion occurs. The pain and flow cease together. 

Diagnosis. — As the expelled matter may be mistaken for the 
products of an early abortion, or a mass of blood clots, polypus, or 
diphtheritic exudations may be spontaneously expelled, a careful 
physical and microscopical examination may be required; this once 
made, no doubt will remain. 

The prognosis for all varieties of dysmenorrhea is for the most 
part favorable. The longer it is let alone, the more difficult it is to 
effect a cure. The difference in the curability depends largely on the 
fact that the impressionability of patients to pain becomes more and 
more marked. Nothing so increases the susceptibility of the nervous 
system to pain, as does the almost constant use, by many of these 
patients, of opiates in some form. Under these circumstances, the 
abuse of opium, and of the whole list of narcotics and stimulants, is 
very great. "They induce a condition of the nervous system, a sub- 
jective state of pain, exaggerating the patient's sufferings, and demand- 
ing relief at any cost, more difficult to overcome than the original dis- 
ease." The neuralgic variety of the malady is more amenable to treat- 
ment than formerly, and the great majority of cases are entirely cur- 
able. The congestive form is easily relieved; the obstructive is con- 
trollable; but the membranous is the most stubborn to combat. 

Treatment of Dysmenorrhoea. — The proper diagnosis is essential 
in all the varieties of dysmenorrhoea. After having determined the 
cause or variety of the painful menstruation, and especially the condi- 
tion of the uterus, the ovaries, the tubes, and the parametric tissues, 
in all cases in which any local examination is justifiable, the treatments 
may be divided into that which is appropriate for the time of the flow, 
to relieve pain, and that which is suitable for the menstrual interval, to 
prevent pain. The latter is more curative than the former. A bad 
constitutional condition favors the disease, and in all long-continued 
cases the general health is undermined. 

We will first consider the constitutional treatment for the men- 
strual times in general. 

For the attack of pain of course no local treatment is needed, 
except what the patient can employ herself. Usually heat applied to 
the seat of pain, rest in bed, and some kind of warm drink, perhaps hot 
water with a little gin or whisky added to it, are about the usual 
methods of home treatment. A great many remedies have been 
employed to relieve pain, but the author will refer to personal experi- 
ence with patients, describing treatments which she has found to be 



Functional Diseases — Disorders of the Uterine Functions. 145 

very useful. Use the galvanic current of electricity, the anode (active) 
over the seat of pain, and the cathode over the lumbar region; give 
about forty minutes' treatment over each seat of pain. Of this treat- 
ment we will speak more definitely further on; but it has been more 
useful, and has given better results in relieving and curing pain in all 
the varieties of dysmenorrhea, than all the medicines the writer ever 
used. It takes plenty of time and patience, and special care that the 
current is properly directed; keep constantly in mind that the anode is 
sedative, and that the current travels from the anode to the cathode, 
and also be sure of the proper time given. 

The medicines usually prescribed are as follows : Pulsatilla ; the 
tincture is useful in the neurotic types of the disease, but is not contra- 
indicated in any form. It is best given in five-to-ten-drop doses, three 
times a day, for a few days previous to the inception of any painful 
period, and should be continued in similar doses, given more frequently 
at the time for pain, if the pain is then present. 

The tincture of cimicifuga may be administered in a similar 
manner. It is useful in the neuralgic form of the disease. It is gen- 
erally efficacious. It is useful in chronic rheumatism, complicating 
menstrual pain, but the salicylate of soda is to be preferred, as we 
know that it has a more specific effect upon all rheumatic complica- 
tions ; it also influences the menstrual flow. 

Guaiacum, in the ammoniated tincture, is said to be useful in the 
rheumatic form of painful menstruation. 

Viburnum prunifolium is beneficial, and is much prescribed, 
united with gelseminum. 

1&: Ext. viburnum prunifolium 3 ij 

Tinct. gelseminum 3 i 

Tinct. cardamoni comp ,1 ss 

Syrupi simplici .% jss 

M. Sig. : Teaspoonful every two or three hours. 

All these last remedies act best when the flow is not scanty. The 
bromides of sodium and of potassium, in ten-grain doses, are given to 
relieve nervousness in the ovarian types of dysmenorrhea. The gal- 
vanic current of electricity is the remedy for cases with rigidity of the 
cervix, and for the spasmodic form of this disease. Gelseminum is also 
prescribed for rigidity. Cannabis indica is a nerve stimulant, an 
anodyne, and an anti-spasmodic. It acts somewhat like ergot, but 
more promptly and energetically. It is to be preferred to opium to 
relieve pain. 

Nitro-glycerine, in doses of one drop of one-per-cent solution, is 
sufficient for young girls fourteen and fifteen years of age, and will 
overcome vasomotor spasms, which are characterized by pallor and 
coldness of the skin. 

Apiole, or apaline, in capsules of three minims each, every two or 
three hours, in cases where severe pains precede the appearance of the 
flow, and in cases where the flow is scanty, is very beneficial. 

10 



146 Functional Diseases — Disorders of the Uterine Functions. 

Opium is most frequently prescribed. It is often abused, and yet 
at times, where the pain is so extremely severe, it has to be resorted to. 
More harm than good has been done by its administration. It is too 
easy a matter to cultivate a fondness for its use. Only an extreme 
necessity would justify its use by the mouth or hypodermically. It is 
better to apply hot fomentations over the seat of pain or use a hot- 
water bag, and bear all the pain possible, before resorting to opium at 
all. Of course the extreme pain calls for its use. Opium is some- 
times prescribed in the form of a suppository, composed of the extract 
of opium, one grain, extract belladonna, one grain, to be given by the 
rectum. Usually one dose is all that is needed. Often nausea fol- 
lows its use. If this is the case, a half cupful of strong black coffee 
relieves this condition, if it is due to the ill effect of the opium. 

All cases of dysmenorrhea are best relieved by rest in bed, from the 
commencement of the flow, and heat applied to the extremities. Dur- 
ing the interval, a constitutional and local treatment is needed. 

Hygienic conditions must first be looked after. The greatest care 
must be observed in regard to good, nutritious diet, bathing, exercise, 
and mental exertion. The bowels should be evacuated daily; and 
systematic cholagogue or liver medicine, with saline mixture following 
the cholagogue eight hours after it is administered, is called for in all 
congestive and inflammatory varieties. 

Marriage in many cases is favorable; bearing children overcomes 
the dysmenorrhoeic state in some cases. Many women who are afflicted 
with dysmenorrhea, are sterile. Such cases require the galvanic cur- 
rent of electricity; the cathode placed in the cervix, and the positive 
placed over the hypogastric region, giving low amperage — from five to 
ten milliamperes — for fifteen minutes, daily, for a week before the 
beginning of the expected flow ; and, if this treatment is persevered in, 
most cases will become fertile, as has been proved by the writer. The 
obstructed cases call for dilatation of the cervix, and curettage, fol- 
lowed, two weeks after the dilatation, by the galvanic current of elec- 
tricity. Many cases have been made fertile under this method. Mar- 
riage is said to be contra-indicated in the congestive, obstructive, and 
membranous variety. The writer believes that marriage is best in all 
cases, since we have the galvanic current added to our list of thera- 
peutical remedies, and the most efficacious of all in this special disease ; 
so that in cases of sterility the congested condition is in a measure 
removed; the patient might become impregnated, which will, in all 
probability, cure the disease. 

Many patients who are sufferers from dysmenorrhea are anaemic, 
and a scanty flow is more common than a profuse flow. Iron is called 
for in these conditions, J. Wyeth & Bros.' iron and manganese, pep- 
tonated. Dose for an adult, from one teaspoonful to one tablespoonful, 
three or four times a day, after meals. The best preparation in pill 
form is the dried sulphate. 



Functional Diseases — Disorders of the Uterine Functions. 147 

R: Dried ferruin sulphate 3 ss 

Quince sulphas gr. xv 

Ext. nucis vomici gr. ij 

Misci et fiat capsules, xxx. 
Sig. : One after meals three times a day. 

Compound syrup of hypophosphites and cod-liver oil are very use- 
ful in fortifying the system. Arsenic is called for when the flow is too 
profuse. In the chronic form of this disease, mercuric bichloride with 
tincture of cinchona is recommended. The general nutrition may be 
improved with cod-liver oil and malt extracts, with a full diet. 
Arsenic and mercuric bichloride in minute doses, long continued, are 
the best remedies for the membranous forms of dysmenorrhea. All 
excitements, both general and local, as well as undue sexual inter- 
course, dancing, and the prolonged nse of the sewing-machine, are to 
be avoided. 

Dilatation of the cervix by expanding forceps, as Goodell's or 
Palmer's, and curettage and packing with gauze, as prescribed, may be 
followed in two weeks with internal uterine treatment, negative and 
active, with a low amperage. This favors the expulsion of any debris 
left from curettage, which is sometimes the case ; it also acts favorably 
in a tonic way, inviting the blood to the illy-nourished uterus, and 
bringing about a normal condition of the organ. In all cases of too 
much flow the positive must be made active in intra-uterine galvanic 
treatment, with a low amperage, from five to fifteen niilli amperes, 
and from ten to fifteen minutes' treatment being sufficient to control 
the abnormal flow. This treatment must be conducted under anti- 
septic precautions, the patient being instructed to take a hot vaginal 
douche, with a little carbolic acid in the water, before coming to the 
office for treatment. The operator must subject all instruments to 
boiling water, and the uterine electrode must be boiled for two or three 
minutes before introducing it into the uterus, and dipped in boiling 
boracic-acid solution just before the operation. The uterine electrode 
may be wrapped at the tip end with a small bit of absorbent cotton, 
very tightly, and a bit of the cotton wrapped along the electrode, far 
enough back to insure it not to slip off in the uterus, when the electrode 
is removed. The bit of cotton holds a little of the boracic-acid solution, 
that you have dipped it in before introducing it. It takes a little 
practise to wrap the electrode evenly and tightly, and with not too much 
cotton, as it would not admit the electrode's being introduced easily; 
but with a little practise this can be easily acquired. In thus pre- 
paring the electrode, it is easier to move it about in the uterus, while 
giving the uterine treatment. During the seance the electrode in utero 
should be moved every three minutes ; first, say, to the left, then to the 
right, next to the upper part of the fundus, then lastly bring down the 
electrode to the internal os of the uterus. If there is much abnormal 
flowing, give as long as five minutes at each move of the electrode, giv- 



148 Functional Diseases — Disorders of the Uterine Functions. 

ing low amperage. From five to fifteen milliamperes will control this 
condition. After giving this treatment, Churchill's tincture of iodine 
may be applied as far up in the uterus as the applicator may be made 
to go without pain ; then leave a cotton tampon, anointed with vaseline, 
well up against the os uteri, with a string attached to it, instructing 
the. patient to remove it the next day and take a vaginal wash. The 
treatment should be made every third day; in some cases every fourth 
day suffices. 

Chauncey D. Palmer, M. D., gives his treatment of dysmenorrhea 
by electricity as follows: "Theoretically, electricity appears to be 
strongly indicated in most cases of dysmenorrhea, and experience has 
substantiated this view. It is especially indicated in the neuralgic 
form of the disease, but it is not contra-indicated in any variety. Gen- 
eral, and possibly local, faradization does good, but the galvanic current 
is more potent for good. It should always be given with an intra- 
uterine metallic electrode, a method which implies that the best anti- 
septic precautions are to be called into requisition. The vagina should 
be washed out with an injection of hot bichloride solution, — one to a 
thousand, — and the intra-uterine electrode, first cleansed and then 
dipped in a strong solution of the bichloride, is applied to the fundus 
uteri, while the other electrode is placed over the abdominal wall. 
The polar effect should always be considered. The positive pole is 
used if the uterine canal is patulous and the menstrual flow is too free 
or too long continued. It is more useful than is the faradic in con- 
trolling pain, diminishing congestion, and lessening irritation; hence, 
as a rule, it is to be chosen. When, however, the menstrual flow is very 
scanty, the uterus small, and its canal contracted, the negative pole 
applied topically will do more good. The seance should continue for 
fifteen minutes at least once a week during the menstrual interval, and 
the strength of the current should be from twenty to forty milliamperes. 
Very few cases will resist this treatment. If it is given with antiseptic 
precautions, and followed by necessary rest, bad results need never be 
expected. 

"The congestive form may be treated in the same way, after 
purgation, rest, and local depletion, if the neurotic element also enters 
&s a factor into the local condition. " 

As we find stenosis existing much oftener at the external than at 
the internal os uteri, it can readily be understood why sterility is far 
more frequent and persistent than dysmenorrhea. When this is the 
case, the spermatic fluid can not effect an entrance into the os uteri, 
and this is often the cause of sterility. It is easier for the menstrual 
fluid to escape than for the spermatic fluid to enter. The galvanic 
current will overcome this condition. The negative pole in this case 
should be used in the os uteri, and the positive over the abdominal 
region, or over the ovarian, or over the fundus of the uterus, externally, 
according to the condition of the uterus and its appendages. 

Continued sterility causes local disease, as catarrh, parenchyma- 



Functional Diseases — Disorders of the Uterine Functions. 149 

tons congestion, displacements of the uterus, and finally sympathetic 
disorders of the ovaries. So vascular are these organs that they can 
not be subjected for years to the hurtful influences of oft-repeated, as 
well as the periodical, influx of blood, without a rest, and yet suffer no 
disturbances in circulation. The only rational treatment for these 
conditions is the galvanic current of electricity. The negative pole, 
which is the most active in its local dilating effect, should be chosen. 

Treatment of Membranous Dysmenovvlioea. — This form is depend- 
ent on some morbid condition of the corporeal endometrium. Some 
writers recommend frequent dilatation and curettage. The writer has 
had the best results from the use of the galvanic current after curettage 
once only. The intra-uterine electrode should always be negative, 
because of its dilating effect. It should be used every third or fourth 
day, giving from fifteen to twenty milliamperes ; seance, ten to fifteen 
minutes. 

Sterility implies an inability for impregnation during normal 
reproductive life. Sterility is either relative or absolute. In the 
former condition there is diminished procreative power; in the latter, 
procreation is impossible. 

Sterility is sometimes congenital, resulting from faulty develop- 
ment. It is said to be acquired when it arises from diseases, after an 
uncertain period of fertility. 

Matthew Duncan says that one marriage in ten in Great Britain 
is sterile. In all probability the percentage is larger in the United 
States. Many women are childless these days in early married life 
from intentional causes, which is to be deplored. 

A marriage may be unfruitful from causes pertaining to either the 
male or the female. More women are said to be sterile than men. The 
ratio is said to be six to one, though it may be less. 

"Sterility," says Palmer, ^exists, however, in men much oftener 
than is commonly supposed. Its greater frequency in women is easily 
understood, when it is remembered that the function of the male in 
reproduction ends with the discharge of the semen, but that the function 
of the female only begins then, and continues for a long time after- 
wards. If impregnation or fecundation occurs, some morbid action 
may interfere with gestation at any time in its course. Sterility, then, 
of course, follows. Fertility implies, therefore, normal fecundation 
and gestation." 

This condition of the sterility of our race should be well consid- 
ered in all its phases, and we implicitly trust that our American women 
will heed the advice given, and carefully study the causes of sterility 
in their case, if it exists, and guard against this evil, especially when 
it is brought on intentionally. If it is due to disease, resort to the 
best medical means for its removal, and persevere until it is over- 
come. You will get your reward for so doing. 

Sterility in the female may arise from disability to perform 
coitus, as the semen must be deposited by the male within the genital 



150 Functional Diseases — Disorders of the Uterine Functions. 

canal of the female. But if there is an imperfect development of the 
vagina, or atresia of the vagina, or an imperforate hymen, or vaginis- 
mus exists, impregnation becomes impossible. Most of the faulty 
developments of the external genital organs of the female may pre- 
vent coitus. Not infrequently the meatus urinarium is situated in a 
mere depression between the labia major a, and it is said that sexual 
intercourse has repeatedly taken place within the urethra. There may 
be a double vagina, — a partition between, — so that there may be 
stenosis ; intromission is then impossible. The labia minora may be 
adherent through their whole length. Great hypertrophy of the labia 
or clitoris may result from tumors of some kind. The hymen may 
not only be tough and imperforate, but also greatly distensible. If 
it is perforate, although it impedes coitus, pregnancy may ensue, for 
a drop of semen that might pass into the vaginal tube may be sufficient 
to give rise to fecundation. 

Vaginismus is a condition of the vulva orifice in which all attempts 
at coitus cause extreme pain. A digital examination, or the insertion 
of a vaginal tube, is attended with spasmodic condition. A vulvar 
or vaginal inflammation, an erosion, or a fissure about the curunculse 
myrtiformei is usually at the bottom of the trouble. Sterility may 
ensue from painful coitus. The causes of dyspareunia (painful 
coitus) are manifold. Among them are vulvitis, vaginitis, milder form 
of vaginismus, rough attempts of the male at coitus, excessive sexual 
intercourse, lacerations of the cervix uteri, uterine inflammation, 
urethral caruncles, fissures of the rectum, painful hemorrhoids. As 
none of these prevent intromission or deposit of the semen within the 
vagina, they need not prevent impregnation. If sterility results from 
any of them, it is not because of the symptomatic dyspareunia, or pain- 
ful coitus, but from the disorders themselves preventing impregnation 
or thwarting gestation. 

Sterility may result from the semen not being able to enter the 
uterine cavity. Under these circumstances coitus may be painless 
and complete, but fecundation becomes impossible from atresia or 
stenosis of the external os uteri, and alterations in the quality and 
the quantity of the uterine discharge. A pin-hole os uteri externum, 
with a conoid cervix, is the most common of the congenital conditions 
creating sterility. 

Uterine flexions and displacements are causes of sterility. 
Chronic endometritis, cervical catarrh, generally increases and alters 
the quality of the uterine discharges. The spermatozoids are washed 
away, and thus prevented from entering the uterine canal ; their vitality 
must be impaired, which is one of the most common causes of sterility. 
The vitality of the sperm, it is said, may be destroyed by excessive 
acidity of the vaginal mucous. This condition exists mostly in mar- 
ried women after one or more children are borne, and constitutes a 
variety of acquired sterility. Any cause which prevents the entrance 
of healthy sperm within the uterine canal may prevent fecundation. 



Functional Diseases — Disorders of the Uterine Functions. 151 

However, fertility may exist when seeming obstructions are found. 
Women vary greatly in their procreative power. Conception has 
been known to take place when the uterus was seriously diseased with 
cancer. 

Sterility may result from an incapacity for proper ovulation. 
This cause is not so easily recognized as are the morbid conditions of 
the uterus, which may be detected by touch or sight. Chronic ovaritis 
comes under this head ; and in some of its forms, such as perioophoritis 
and cystic degeneration, it impairs the ovule. Imperfect development 
of the ovule may also result from any general disability, as anaemia, 
scrofula, tuberculosis, or syphilis. Obese women are frequently found 
to be sterile, evidently from imperfect ovulation. A rich diet and a 
life of luxury and ease surely diminish fertility. A spare diet, with 
plenty of exercise and work, seems to favor it. Compare the wealthy 
with the poor. While the poor are very fertile, the rich, many of them, 
are childless. 

Gonorrhoea, no matter how contracted, is a very common cause 
of sterility in women. It causes vulvitis, vaginitis, and inflammation 
of the vulvo-vaginal glands, with urethritis, and cystitis, and oophoritis. 
Gonorrhoea in either sex is a stubborn and long-continued disease. It 
has many complications in both sexes, but especially in women. In 
some cases, no doubt, it has an indefinite continuance; but cure is not 
by any means impossible. 

Sterility may result from organic changes in the ovary or the fal- 
lopian tubes (hydro-, pyo-, or hsemato-salpinx), or from pelvic peri- 
tonitis, mechanically preventing an instinctive application of the 
fimbriae to the ovaries. 

Sterility may arise from inability to continue and complete gesta- 
tion, which we so often meet with in cases of retroversion of the uterus. 
Although the sperm finds its way into the uterine canal, and fecunda- 
tion takes place, or conception and gestation have occurred, still, for 
some reasons, fertility ceases, and abortion occurs early in gestation; 
and this is frequently the case. 

It is said ninety per cent of all child-bearing women abort once 
or oftener, during their lives. One out of twelve pregnancies, end in 
an abortion. 

Abortion may take place from fright, grief, traumatic causes, and 
from general disease. The causes are "paternal, maternal, and foetal." 
Syphilis is a very common cause. Catarrhal and syphilitic inflamma- 
tions prevent and arrest gestation. The development of the embryo 
depends very much on a normal condition of the decidua, and the 
healthy decidua depends very much on a healthy endometrium and a 
healthy womb. 

There may be sexual incompatibility, from want of physical 
adaptation of the parties. A married life has existed for years ; sep- 
aration has been mutually agreed upon ; and when either party obtained 
a new companion, fertility has been the result. Napoleon Bonaparte, 



152 Functional Diseases — Disorders of the Uterine Functions. 

for instance, had no child by Josephine; a divorce followed in conse- 
quence; he married again, and became the father of a child by his 
second wife. Josephine was fertile by her first husband. This seems 
to show that there are some physiological differences in the spermato- 
zoids or the ovules of different persons. 

Consumption in either sex does not show diminished fertility. 

Women very young in years have conceived long before puberty, 
while others advanced in years have been delivered long after meno- 
pause. 

*; Conception has occurred after a rape, or when the female has been 
under the influence of an anaesthetic, or stupefied by alcohol or nar- 
cotics, and not infrequently when she is perfectly passive or disgusted 
with sexual intercourse. 

Many women prolong lactation/ or time of suckling, to prevent 
another pregnancy. However, lactation does not always prevent con- 
ception. 

It is said: "The causes of sterility in the male are impotency, 
and also azoosperma, when the seminal fluids contain no spermato- 
zoids, or only such as have feeble vitality. The microscope alone 
detects this condition, which is found in men sometimes who are other- 
wise in good health and normal vigor." 

The diagnosis of the morbid condition producing sterility is of the 
utmost importance. 

Success in the management of sterility depends very largely upon 
a correct diagnosis. At times all the means of diagnosis in both sexes 
may be required. 

Prognosis is certain and favorable in some cases, uncertain and 
unfavorable in others, according to the conditions present. 

The removal of the cause, if practicable, is the treatment. A 
correct diagnosis is required to determine as to whether the fault lies 
in the husband or in the wife. In all cases of long-continued sterility, 
after having thoroughly examined the wife, without finding a satis- 
factory cause for the sterility, the husband should be looked after in 
the same way. "Some of the semen may be obtained from the vagina 
of the wife, within a short time after coitus, for a microscopical exam- 
ination. In case the cause is found with the husband, he should be 
treated for sterility, as it would be useless to treat the wife," 

It is not the place here to speak of the treatment or management 
of sterility in the husband. It is necessary, however, for the wife to 
know that the cause of barrenness in her case is not always her fault, 
but often her husband's. 

For barrenness in the woman we remove and correct, as best we 
can, all causes which impede coitus. An atresia of the vagina, an 
imperforate hymen, or a vaginismus is to be treated by appropriate 
methods, which are surgical means. If there is painful coitus from 
vulvitis, vaginitis, vulva-hyperassthesia, endometritis, chronic metritis, 
chronic ovaritis, ovarian prolapse, displacements of the uterus, or a 



Functional Diseases — Disorders of the Uterine Functions. 153 

diseased urethra, bladder, or rectum, all of these diseases need special 
treatment, care, and attention. The removal of these diseases may 
prolong life, make the life of the patient more comfortable, and espe- 
cially enhance the chances for impregnation. 

In case of displaced uterus or flexions, the organ is to be replaced 
and kept in position by the means of surgical procedure and vaginal 
tampons and properly-fitting pessaries. The pin-hole os uteri, or 
stenosis, is best overcome by the galvanic current, placing the cathode 
or negative in the ostium uteri, and the positive over the abdominal 
region. Give from fifteen to thirty milli amperes ; seance from five 
to fifteen minutes, being always governed by the chronic condition of 
the cervix as to whether catarrh is complicating the trouble. Curet- 
tage may be resorted to in some cases of catarrh of the endometrium 
and cervix before commencing the use of the galvanic treatment. 
Dliation and curettage should be followed with an application of 
Churchill's tincture, after all bleeding has ceased, from washing out 
the uterus with a bichloride of mercury solution, 1 to 3,000, followed 
by rinsing with sterilized water ; then apply the tincture as above men- 
tioned, after which pack with sterilized gauze. Give a hot vaginal 
douche every day for a week, using an antiseptic. Rest in bed must 
be the rule. In two weeks after the curettage the galvanic current 
should be employed, and the treatment should be repeated every fourth 
day for a month. The patient may now rest from all local treatment 
except a warm douche at bedtime, as a hygienic measure. 

Rare indulgence in sexual intercourse is said to favor fertility. 
Abstinence from coitus for months at a time is in some cases beneficial, 
not only by curing the disease which causes sterility, but also by 
increasing the chances of impregnation. 

If the uterus is very small or illy developed, it may be stimulated 
to grow by means of the faradic current of electricity^ provided the 
patient is young and otherwise healthy. The cathode uterine elec- 
trode is to be placed in the cervix uteri, and the anode, or positive, over 
the hypogastric region ; give the strength that the patient can com- 
fortably bear ; seance from twenty to thirty minutes. The ovaries 
may also be treated by placing the cathode over the ovary and the anode 
over the small of the back, about the waist line, on the side of the spine 
corresponding to the ovary to be treated, whether the right or the left. 
Give from fifteen to twenty minutes' treatment over each ovary. This 
should be repeated daily, or three times a week, for several months, 
until a more normal condition results. A lacerated cervix calls for 
an operation. 

The question is often asked, "When is impregnation most often 
likely to occur ?" Fecundation may, in some cases, occur at any time 
during the month. It is most apt to occur within a week or ten days 
after the cessation of the menstrual flow, or it is likely to occur a day 
or two before the menstrual period. Undue frequency of coitus may 
cause abortion. Excessive acidity of the vagina may cause sterility. 



154 Functional Diseases — Disorders of the Uterine Functions. 

This is corrected by the use of the vaginal douche, with a teaspoouful 
of borax to one quart of warm water. Use night and morning. Good 
tonics are of great value; tonics of iron, quinine, strychnine, arsenic, 
phosphorus, cod-liver oil, and the faradic current of electricity to tone 
up the nervous system — these improve the general health, and also favor 
fertility. 

CHLOROSIS. 

Chlorosis is a disorder of nutrition, a form of ansemeia char- 
acterized by an abnormal condition of the blood. It is not so com- 
mon in the male as in the female. It is usually associated with a dis- 
turbance of menstruation, and very often it appears at the time of 
puberty, when the reproductive organs are developing. It is frequently 
a disorder resulting from illy feeding children. Special disorders of 
nutrition follow improper feeding, defective hygienic surroundings, 
overworked girls, as in schools, factories, and clerks. Chlorosis may 
also be due from lack of sufficient exercise in the open air, and from 
impure air and undue strain in mental exertions. It is met with in 
girls in upper classes of society and of good physical inheritance. 
There is always an anaemic state of the blood, the red blood-corpuscles be- 
ing deficient in number and lacking richness in hsemoglobulin. In this 
disease the heart and blood-vessels are said to be usually small, but a 
compensatory hypertrophy of the heart may at times be present ; there 
may be a defective growth of the ovaries and the uterus in chlorosis. 

The symptoms are those of anaemia, as shortness of breath, palpi- 
tation of the heart, and a swooning away. The pulse is accelerated 
and easily excited ; the complexion is peculiar, having a -curious yellow- 
green color; hence the name "green-sickness." The appetite is vari- 
able and disordered, and there is indigestion and constipation. Men- 
struation is almost always deranged, and often hysterical. Amenor- 
rhea is very common. Menorrhagia is rare. It may be a constitu- 
tional disease, due to syphilis or some organic disease of the stomach 
or kidneys. 

The treatment for chlorosis is iron, which is considered almost a 
specific. It should be given in moderate doses for a long time. The 
writer has found Gude's pepto-mangan of iron the best preparation of 
iron in these cases. J. Wyeth & Bros.' solution of iron peptonate 
and manganese is good. Dose for an adult, from one teaspoonful to 
one tablespoonful after meals, three times a day, in water, milk, or 
wine. There are other preparations of iron which are prescribed: 
The dried sulphate 

IJ: Ferri redactii pulv 9 ij 

Quiniae sulphatis 9 ij 

Acidi arseniasae gr. j 

Ext. gentian q. s. 

M. et fiat massa pil, no xl. 

Sig. : One pill after each meal, three times a day. 

Tincture of nux vomica in one and two-drop doses, half an hour 



Functional Diseases — Disorders of the Uterine Functions. 155 

before each meal, is always good in cases of chlorosis. The nux may be 
taken with hydrochloric acid. 

IjL: Tinct. nucis vomici 5 jss 

Acid hydrochloric E j 

M. et sig. : Five drops, half an hour before meals, in a small wine- 
glass of water, three times a day. 

While medicines are being given, a strict attention should be paid 
to hygiene, diet, and exercise in the open air. The diet should be very 
nutritious. Eggs and milk are the best to enrich the blood quickly. 
Egg must be taken raw, beaten up with a pinch of salt, or taken with 
port wine, three times a day. Take one in the morning, another in 
the middle of the afternoon, and the third on going to bed. Milk and 
other nutritious foods should be eaten at regular meals. If the milk 
causes distress, flatulence, or indigestion, which is often the case, try 
taking it hot ; and if it still causes distress in the stomach, malted milk 
may be taken. Harlock's is the best preparation. Beefsteak should 
be very tender ; or the beef may be scraped and made into little cakes, 
cooked quickly on a hot griddle, and served while hot. It is easy of 
digestion, and is very palatable. Malt and cod-liver oil are useful in 
some cases, when there is struma, or consumption, or cancer in the blood. 
Exercise in the open air, taken freely as can be borne with comfort, 
is necessary. 



CHAPTEK VII. 

DISEASES OE THE NEEVOTTS SYSTEM DEPENDENT 
UPON DISOEDEES OF THE PELVIC OEGANS. 

The various systems of the female economy are in intimate rela- 
tions with the pelvic organs in health and disease. Chauncey D. 
Palmer, M. D., says: "Hystero-neuroses are phenomena simulating 
morbid conditions in an organ anatomically healthy, but due to morbid 
changes in the uterus and ovaries. Of these two, the uterus is usually 
the offending one. There is a sympathetic hyperesthesia, due to reflex 
action, from uterine derangement. This is proved by the fact that 
these phenomena are intractable to treatment addressed to the symp- 
toms, but are amenable to treatment directed to the causative pelvic 
disorder. 

It is a matter of daily occurrence to witness the disorders of preg- 
nancy. Almost as frequently we see the physiological changes from 
menstruation in the system at large, particularly at puberty and at the 
menopause. They are varied in character, as determined by ramifi- 
cations of the ganglionic and spinal nerves and centers. When the 
organ receiving the impulse is in a state of lowered vitality and lessened 
resistance, or of hyperesthesia, or when the nerve tracts-are in a condi- 
tion of morbid irritability, the reflexes are stimulated and heightened. 
Hence disorders of many parts of the body, the nervous system in par- 
ticular, arise from functional or organic changes of the pelvic organs. 

Excitability is a common property of all living parts, and is an 
essential condition of life. A great variety in the alterations, as regards 
seat, character, and intensity, renders it impossible to connect them at 
all times with symptoms of any definite kind. 

Menstruation, in its systemic phenomena, modifies goitre, the dis- 
eases of the skin, varicose veins, fibroid tumors, and the circulatory 
changes of the brain in health and disease. The influence of disor- 
dered menstruation manifests itself in the brain as sleeplessness, 
melancholia, dementia, and mania ; in other parts of the nervous system 
as local paralysis, epilepsy, and catalepsy ; in the heart as palpitation ; 
in the lungs as cough and dyspnea; in the stomach as nausea, vomit- 
ing, and indigestion; in the intestines as tympanitis and diarrhea; in 
the kidneys as hyper-secretion of the urine ; in the skin as eczema and 
acne ; in the breasts as disturbances of the lacteal secretions, pain, and 
localized enlargements ; in the joints as pain, false anchyloses, etc. 
But for all practical purposes we may say that the resulting disorders 
of the nervous system partake of the nature of chorea, hysteria, epilepsy, 

(156) 



Diseases of the Nervous System. 157 

hystero-epilepsy, migraine, and neurasthenia. These, together with 
nymphomania, and other varieties of a sexually perverted appetite, as 
onanism and insanity, are especially referred to. 

An irritation starts from the site of an organic lesion, and pro- 
ceeds to the nerve cells at the base of the brain and the upper part of 
the spinal cord. Reflex action of the sympathetic nerves explains 
many of the diseases of women. Any irritation will travel on the line 
of least bodily resistance, and the degree of transmission depends also 
on the subject affected. Through this irritation the nerve-cells undergo 
alteration of their nutrition ; after a time they acquire a morbid excita- 
bility, which is the essence of the disease. We may never know what 
cells are altered. The change in them may be more dynamical than 
physical. The microscope may be unable to detect any differences. 
No special lesion is constantly present. Recent pathology has taught 
us how serious distant diseases may be, started through reflex action 
and changes. 

CHOREA. 

Definition. — Chorea is a non-febrile disease, not necessarily 
dependent upon demonstrable organic affections of the nervous system, 
usually occurring in childhood, characterized by generalized choreic 
movements of nerve power. 

Etiology. — "Neuropathic heredity, luxury, poverty, or whatever 
lessens the robustness of the nervous system of the child, predisposes 
to chorea. The disease is much rarer among negroes than among 
whites ; it is more frequent among girls than boys ; about four-fifths of 
the cases occur between the fifth and the fifteenth years." — Wood and 
Fitz. 

Chorea, like other diseases connected with nervous exhaustion, is, 
in the northern United States, much more frequent in the spring, prob- 
ably on account of the lowered nerve tone produced by the long winter. 
So large a proportion of the sufferers from chorea are of the rheumatic 
diathesis, and so frequently does chorea develop from or into rheuma- 
tism, or alternate with that disorder, that there must be some relation 
between the two affections. It is thought that chorea may be due to 
various poisons acting upon the nervous system, which is predisposed 
to the disease. Chorea might thus be defined as a peculiar condition 
of the whole nerve tract, capable of being produced by various poisons, 
and also by other disturbing agencies, such as violent emotions or 
anatomical alterations, the latter, perhaps, being due to widespread 
thrombosis. The action of these causes is favored by the existence of 
a peculiar predisposition of the nervous system to become choreic under 
their influence. 

Chorea is prone to recur, not because one attack predisposes to 
another, but because a pre-existing foundation weakness renders the 
nervous system easily thrown off its balance. 



158 Diseases of the Nervous System. 

It must be remembered, however, that chorea may be developed 
in a few minutes from fright, and is usually recovered from in a few 
weeks ; hence it is said by some writers that it is absurd to suppose that 
it is necessarily based upon serious organic changes of the nerve-centers. 

Since choreic movements may originate in either the brain or the 
spinal cord, and the condition of the knee-jerk in the choreic child 
demonstrates that the ganglionic cells of the cord are in an abnormal 
condition, it seems clear to the writer that the basal lesion of St. Vitus' 
dance is a change in the nutrition of the ganglionic structures of the 
whole cerebro-spinal axis. 

*■> In the chapter on children's diseases we will speak more fully on 
chorea, as it is a child's disease. 

Pregnancy is a very common cause of chorea, when it is due to 
the violent and incessant movements of the foetus, depriving the sufferer 
of sleep, and causing a rapidly-progressive exhaustion; and no time 
should be lost in bringing the patient under the influence of chloral 
and opium, aided by small doses of antipyrin, also the bromides. 

The most important diagnostic symptoms of chorea are the rigidity 
and the tendency to rythmical movements in hysterical cases. In 
chorea the movements are incoherent, and devoid of character or 
rhythm. It consists in an exaggeration of those muscular movements 
which are constantly taking place, especially in children who have not 
yet acquired the power of governing the actions of their movements. 

Treatment. — The treatment consists in removing any tangible 
cause. The food should be highly nutritious and of easy digestion. 
Fats are one of the essential elements in diet. Quiet and rest in bed, 
combined with nutritious food, do more good than medicines. Sea air 
and sea bathing are highly recommended. Added to these, the gal- 
vanic current of electricity aids in controlling the muscular twitching. 

Moral treatment is important. Remove mental strain, control 
study, correct improper habits, and strengthen will power ; all these are 
patent means to regulate the life of a choreic patient, and are always 
attended with good results. 

Arsenic in small doses is useful. Cod-liver oil, when it agrees 
with the patient, is beneficial. Cimicifuga, strychnine, iron, and 
quinine are remedies that are used in choreic conditions. 

HYSTERIA. 

Hysteria is a functional disturbance of the nervous system, with 
much mental perversion. Most usually hysteria is confined to the 
female sex, but it is not always so limited. Hysteria is not dependent 
alone on uterine or ovarian diseases. When the disease presents itself 
in a female, there may not be any tangible evidence of any pelvic dis- 
order. However, local affection of the genital organs has much to do 
toward provoking an attack. Hysteria is more common during preg- 
nancy, and its symptoms are most liable to occur at the menstrual 



Diseases of the Nervous System. 159 

periods. Erosion or lacerate cervix and chronic endometritis are 
responsible for attacks of hysteria. Dysmenorrhea and mal-position 
of the uterus produce and perpetuate hysterical conditions in subjects 
predisposed to it by inheritance. Sedentary habits, idleness, vicious 
habits and practises, or any excessive development of the emotional 
nature, are also causes. Hysterical symptoms subside when the local 
causes or diseases are removed. Ovarian disease, also oophoralgia, 
ovaritis, and prolapsus of the ovaries, are causes of hysterical attacks. 
See chapter on hysterics in children. 

Treatment. — The treatment is to deal with all cases according to 
all tangible causes, if practicable, and according to each individual idio- 
syncrasy. Always improve the appetite if it is poor; correct the 
indigestion; direct a regular nutritious diet; secure daily, normal 
alvine evacuations ; open-air exercise to the extent of fatigue must be 
insisted on. Read wholesome literature only, as it supplies the best 
food for the mind. Cold baths are good in some cases ; cool sea bathing 
is also valuable in many cases. 

Anaemia and debility are to be treated with vegetable tonics and 
iron with cod-liver oil. Cimicifuga is a valuable remedy if there are 
menstrual derangements. Strychnia? is not so good, as it aggravates 
the disease. The use of alcohol and narcotics should always be avoided. 
For the convulsions, when there is no doubt that they are due to 
hysteria, a sudden shock may be given to the nervous system by pour- 
ing cold water over the head and face, which is often followed by a 
return to consciousness, and a suggestion of its repetition may prevent 
another attack. Amyl-nitrate, a drop or two on a handkerchief applied 
to the nostrils, will quickly arrest the spasm or paroxysm of hysteria, 
or hystero-epilepsy. The bromides are the best remedies during the 
intervals between the attacks. Local paralysis is best managed with 
massage and electricity. Aphonia usually yields to the treatment of 
the galvanic current of electricity. 

Disease of the uterus should be treated with the galvanic current, 
and all displacements corrected. Oftentimes friends and family are 
deleterious in their influence. In such cases change the surroundings. 
A visit away from home does much good. Excessive sympathy does 
as much harm as ridicule and abuse. Over-solicitude during an attack 
aggravates and prolongs it, as well as renders it more frequent. Gain 
the confidence of the patient, and arouse her to systematic exercise of 
her own will-power and self-control. General faradism is good in 
many cases. 

Dr. Weir Mitchell's treatment of incontrollable hysterical patients 
is by seclusion, rest, forced feeding, massage, and electricity. 

!N"o doubt many cases of hysterics are due to walled-in exudate 
about the uterus, being due to peritonitis or inflammation of the cellular 
tissues, leaving an unabsorbed exudate having a boggy feel to the touch. 
The writer has recently had three cases where these patients were thus 
affected with hysterical attacks from this lesion. Rest in bed, nutri- 



160 Diseases of the Nervous System. 

tious food, and the galvanic current of electricity, three seances a week, 
tonics of iron, quinine, cod-liver oil, port wine, and raw eggs, vaginal 
douches, saline laxatives, was their treatment ; they were relieved. 

Another form of hysterics results from a diseased condition of the 
fallopian tubes and ovaries. Some of these cases call for surgical 
operations. The record shows that operation does not always relieve 
the patient. Again and again have the attacks continued as bad as 
before the operation. Give general constitutional treatment, massage, 
tonics, open-air exercise, nutritious food, a change of scene, and gen- 
eral hygienic measures. 

MIGRAINE, OR HEMICRANIA. 

Definition. — A hereditary paroxysmal headache, without any 
obvious cause, usually appearing at puberty and gradually disappearing 
after the age of fifty. 

Etiology. — The only known cause is heredity. We have no knowl- 
edge, it is said, of the basal nature of migraine. The paroxysms are 
described as being evidently of the nature of nerve-storm, which was 
thought by Trousseau to have a relation to epilepsy. There are said 
to have been cases in which migraine and epilepsy coexisted ; others in 
which the two forms of paroxysms seem to replace each other. The 
best explanation of the rare cases is thought to be the coexistence of two 
neuroses. The relation, on the other hand, between migraine and gout 
seems very close. 

Symptoms. — Migraine occurs in paroxysms which may be sepa- 
rated by a few hours or many months. The attack is usually preceded 
by malaise, chilliness, and a sense of languor, or more rarely by a 
condition of exhilaration. In most cases the pain commences in the 
forehead near the supra-orbital foramen, and gradually increases in 
intensity until it becomes unbearable. It is variously described by 
sufferers as boring, throbbing, or shooting pain, and it is sometimes 
situated in the occipital region. After a time, repeated vomiting 
occurs, with relief, which may be immediate or gradual. The whole 
paroxysm lasts from five hours to two or three days, and is often accom- 
panied with intense intolerance to light and sound, and presents dis- 
tinct hysterical manifestations. In some cases there is aphasia during 
the height of the paroxysm. Vomiting may be absent. 

An attack may be ushered in by an aura, or a roaring in the ears ; 
in most cases it takes the form of a disturbance of special sense. 
Rarely a peculiar bitter or a very disagreeable taste, or it may be a 
peculiar odor, marks the coming on of a paroxysm. The sounds are 
variously described as like that emitted from a marine shell applied to 
the ear, or a gurgling similar to that which is heard when water enters 
the ear during bathing. 

An attack of migraine is usually attended with emotional depres- 
sion, which may amount to a brief melancholy. 



Diseases of the Nervous System. 161 

Diagnosis. — The diagnosis of migraine, usually easy from the his- 
tory of the case, is to be confirmed by the exclusion of other causes of 
the attack and by a study of the family history. 

Prognosis. — Migraine is said to be practically incurable, but 
abates after middle age, and is often ameliorated by treatment. 

Treatment. — Treatment of migraine consists in the building up of 
the general health of the patient. The better the health, the fewer the 
attacks. Eye-strain must be carefully guarded against. The contin- 
uous administration of cannabis indica is often of great service in 
lessening the number and the severity of the fits of headache. "A 
known extract should be given in ascending doses until it produces mild 
symptoms of intoxication, and then a dose just within the limit of the 
full physiological dose should be administered, three times a day, for 
a month. Caffein, antipyrine, and antifebrine are often useful in 
alleviating the pain in migraine attack, and will in some persons abort 
a paroxysm." Of all palliatives the most certain is the combination 
of deodorized tincture of opium with potassium bromide. Ten 
minims with sixty grains may be given in two doses, in water, two hours 
apart. 

The danger of forming the narcotic habit is never to be lost sight 
of in a disease so chronic as migraine. 

A very efficacious combination is : — 

1£: Zinci phosphidi grs. ij 

Strychnine grs. ss 

Ext. cannabi indicse grs. x 

M. et fiat massa in pil ulae xx. 

Sig. : One pill three times a day during the intervals. 

Tincture of mix vomica can be given in doses of one drop every 
fifteen minutes to every half hour in cases attended with stomach 
disturbances ; may give several doses if necessary. 

Sodium salicylate, in doses of three grains every half hour, is 
sometimes very efficacious in gouty diathesis. Ammonium bromide 
and antipyrin form an excellent combination. 

The bromides are admirably adapted to headache attended with 
cerebral irritability and excitability. They arrest functional activity 
of the brain, secure sleep, and diminish congestion. Brain weariness 
and exhaustion are most favorably influenced by caffein and guarana. 
Caffein is a powerful cerebral stimulant ; it is also a heart tonic, increas- 
ing the arterial blood pressure. It is one of the best remedies that we 
have to increase absolutely the activity and the capacity of the human 
brain for work. Headache due to brain exhaustion and anaemia 
indicate its use. 

Cannabis indica, given in doses of seven to ten drops every three 
hours, is one of the most trustworthy remedies for an attack of sick- 
headache. Its use is called for in cases associated with or dependent 
upon such menstrual disorders as menorrhagia and dysmenorrhea. 
All cases are benefited by sitting up, and by being quiet in a dark room. 



162 Diseases of the Nervous System. 

Cold to the head will do good in the paralytic form of the disease, and 
hot water in the spartic form. 

Galvanism persistently used has produced good results. It is 
both prophylactic and curative. Almost every attack is relieved by it, 
but its successful employment must be based on scientific principles, 
keeping in mind that the current passes from the positive to the nega- 
tive pole. Apply the anode or positive pole over the frontal region, 
and the cathode or negative pole to the lower cervical region, or between 
the shoulders over the spine. Give five to ten milli amperes ; seance 
ten minutes. In case of paralysis the current should be reversed. 
The cathode is applied to the forehead, and the anode is placed in the 
hand. If the pain should be in the region of the temple, the positive 
should be placed over the seat of pain, and the negative pole in the hand 
corresponding to the right or left temple to be treated. Give from ten 
to twenty milliamperes. Seance ten minutes, over the seat of pain. 

For nausea the anode is placed over the epigastric region, and the 
cathode in the hand. Give from thirty to fifty milliamperes. Seance 
ten minutes. Seance should be given daily until relieved; then about 
three times a week, for three months, when the patient may rest from 
the treatment. 

NEURASTHENIA AND SPINAL IRRITATION. 

"Neurasthenia. — This is a constitutional neurosis, which is due 
to deficiency or exhaustion of nerve force, or the lack of power of the 
nerve centers, not dependent upon the existence of organic disease in 
any part of the body." 

Etiology. — Primary neurasthenia has, for its predisposing cause, 
an original feebleness of constitution of the nervous system. Spinal 
irritation, a local neurosis, is a symptom of spinal exhaustion. It may 
be produced by overwork, especially when this overwork is combined 
with emotional strain. Both of these conditions, especially the latter, 
are much more common in women than in men. Spinal irritation is 
most frequent in the higher classes of society, in women between fifteen 
and forty-five. 

Symptoms. — Neurasthenia may be local or general. The develop- 
ment of general neurasthenia is very frequently preceded by a local 
neurasthenia. "This cerebral asthenia, the result of mental over- 
work, or a sexual spinal asthenia, the result of sexual excess, may exist 
by itself, but in most cases the local weakness is soon followed by a gen- 
eral neurasthenia. Usually neurasthenia develops slowly, but it may 
develop abruptly. The symptoms vary in accordance with the por- 
tion of the nervous system affected. They may be generalized as a 
loss of power of performing functional acts, associated with great 
irritability. Thus the loss of power of fixing attention, slight weak- 
ness of memory, disturbance of sleep, sense of weight and contractions 
in the head, ringing in the ears or head. We often hear neurasthenic 



Diseases of the Nervous System. 163 

patients say that depression of spirits, great distress on mental effort, 
are the usual manifestations of a brain exhaustion, while failure of 
muscular power, of endurance, of sexual power, of vasomotor power, 
of control over circulation, results from weakness of the lower nerve 
centers." 

Coccygodynia. — This is a distressing form of spinal irritation 
affecting the tip end of the spine, in the region of the coccyx. It often 
accompanies irritation of other portions of the spine. 

The vasomotor symptoms are, excessive blushing on the least 
provocation or on the use of alcohol, cool extremities, occasional pallors, 
excessive sweating at night and during sleep, or during emotion or 
excitement. These are ordinary symptoms. The heart is often very 
irritable — palpitation, shortness of breath, and exaggerated increase of 
the pulse upon exertion being usually present. The patient is unequal 
to the ordinary routine of daily life. Everything to be done fatigues 
the brain ; even to think of having it to do is fatiguing. Even talking 
and thinking are exhausting to the patient, who becomes subject to 
many morbid fears. Most all neurasthenics are easily agitated, very 
sensitive, and timid. They are usually spare in body, anaemic, broken 
down in health, and at times bedridden. There is predisposition to 
chorea and hysteria. 

Neurasthenia has a great variety of causes. A bad inheritance 
in the way of temperament, lack of judicious physical exercise in youth, 
undue strain of the brain in study or occupation, social disappointment, 
business excitements and anxiety, and pelvic disease, are said to enter 
into the causation of this trouble. Female sexual disease, no doubt, is 
a direct cause. Any female disease which gives pain, frequent men- 
struation, or profuse leucorrhoea may soon bring about neurasthenia. 
Chronic uterine and ovarian diseases are liable to be responsible for 
this condition. Cervical tears almost always heal by second intention, 
and by the formation of some cicatricial tissue. They bring about 
erosions, eversions, granular degeneration, cystic degeneration, and 
chronic uterine catarrh. Pain is created, and reflex disturbances are 
set up. The morbid condition of the cervix uteri demonstrates in a 
greater degree these results of the varying susceptibility of the nervous 
system to pain and reflex irritability. 

Treatment. — The rest cure, elaborated by Weir Mitchell, is most 
useful, and should be resorted to in the beginning of all female 
neurasthenics due to pelvic diseases or any uterine disease, com- 
bined . with massage, seclusion for most cases, forced feeding, rest, 
and electricity. No one of these can be safely omitted. A tired brain 
is thus put to rest as the mind is diverted and not excited. Massage 
given once or twice a day gives the needed exercise to all parts of the 
body without exertion ; sleep is secured ; pelvic congestion is diminished 
by the recumbent position of the body. The circulation is equalized 
by massage. The nutrition is favored by forced feeding. Excre- 
tion is not neglected. The tonic effects of electricity are obtained by 



164 Diseases of the Nervous System. 

the well-regulated administration of this agent. This special treat- 
ment, "rest cure/' starts life anew. A complete transformation is 
often inaugurated, and all are benefited by it. 

The Galvanic Current. — The positive pole should be active in 
cases of spinal irritation. 

Some writers recommend the positive pole being placed to and 
below the region of the spinal tenderness, while the negative pole is 
placed at the sixth or seventh cervical vertebra. 

The writer has used the positive pole over the seat of tenderness, 
where there is any enlargements or thickening of the cartilages, and 
the negative at some place below, or on the thigh. Seance from ten 
to twenty minutes, giving from forty to fifty milliamperes. In case of 
Pott's disease, the cathode is placed over the diseased vertebra, or over 
the seat of the lesion, and the positive over the chest. Give from 
twenty to thirty milliamperes; seance, ten minutes for each move of 
the poles. The galvanic current should be given daily, until pain and 
tenderness have ceased ; then three seances a week, until the patient is 
considered cured. General faradization is especially useful in these 
cases ; placed in the rectum it overcomes constipation. Arsenic is con- 
sidered one of the best medicines; cod-liver oil, iron, and phosphorus 
are good. Arsenic is best for persons of the lymphatic or nervous tem- 
perament. Fairchild's Elixir of Calisaya Bark and Zinc Phosphite 
is highly recommended. Cod-liver oil, pure or emulsified with the 
syrup of lacto-phosphate of lime, is prescribed during the winter 
months. 

Sufficient sleep is always to be secured by systemic muscular 
exercise in the open air, by a quiet life, and by early retiring to rest, 
aided by the administration of some easily digestible food, as beaten 
egg, or a glass of warm fresh milk, or a cup of hot malted milk (Har- 
lock's). Wyeth's liquid malt is the best form of alcohol to be pre- 
scribed. Alcohol must be carefully prescribed. 

In no class of disease is it more obvious than in this, that success 
in the management of the various neurasthenic conditions is largely 
in proportion to the degree in which the patient is won in confidence, 
thus stimulating her faith. Intelligent cooperation of all will be 
rewarded. 



CHAPTER VIII. 
INSANITY. 

Definition. — Insanity is a mental condition of aberration suffi- 
ciently intense to overthrow the normal relations of the individual to 
his own thoughts and actions, so that he is no longer able to control 
them through the will, this condition being independent of known 
structural alterations of the brain. This definition does not include 
cases of mental aberrations which are commonly known in the court- 
room as insanities, but in which there is a distinct organic disease ; in 
other words, it does not include the so-called organic or complicated 
cases of insanity. 

The following I quote from Wood and Fitz: "Insanity is not a 
distinct disease, but an abnormal state, varying indefinitely in its 
intensity, and separated by no tangible line from sanity. Its mani- 
festations are simply alterations, exaggerations, or perversions of the 
normal faculties, and therefore offer nothing that is absolutely dis- 
tinctive. Emotional depression deepens into a pronounced melan- 
cholia; emotional exaltation lifts itself into the highest mania, by 
insensible gradations, and who shall say where the dividing line is 
between the state in which the man is master of the mood, and that in 
which the mood is master of the man ? The insane, morbid impulse 
is but an exaggeration of what bids a man standing on the verge of 
some great height, to plunge headlong, or which, spreading from breast 
to breast, fills a mob with reckless rage, or scatters it in apparently 
causeless panic. 

"Insanity being a symptomatic condition, and not a disease, it is 
incorrect to consider its different forms as distinct diseases ; but for the 
purposes of discussion it is necessary to associate cases in symptom 
groups, to which names are given. The naming of these symptom 
groups has a distinct tendency to lead to the delusion that they are dis- 
eases, hence melancholia, mania, etc., are continually written about as 
though they were of equal rank with typhoid fever or scarlatina, 
whereas they are simply parallel groups to diarrhea, paralysis, or 
dropsy. They are not distinct diseases, as is shown by the facts ; first, 
similar mental symptoms may be produced by various organic brain 
diseases, and that one organic brain disease will cause, or may cause, 
antagonistic forms of insanity; thus in paretic dementia, now there 
may be maniacal conditions, now a melancholic one. Second, not only 
does every grade of case exist in nature so that acute mania grades into 
acute melancholia without distinct lines of demarcation, cases not 
infrequently occurring which may with equal propriety be referred to 

(165) 



166 insanity, 

one or the other of these so-called diseases, but also in a single attack 
of insanity the form may change without appreciable cause, so that the 
patient to-day has mania and to-morrow melancholia. 

"The insanities included in the definition given above are divided 
into, first, constitutional insanities ; second, pure insanities. " 

Insanity is either of central or of reflex origin. For our present 
purposes all cases may be classified as follows: First, those which are 
purely central, from cerebral causes ; second, those which are the result 
of female sexual disease, from reflex causes. 

i In this chapter we will speak only of cases which are purely reflex 
from pelvic causes. These cases are noticed about the age of puberty, 
after marriage, during and following parturition, and at the climacteric 
period. These times appear to be the periods of special susceptibility 
in women. At the same time we must remember that purely central 
conditions produce or arrest pelvic symptoms, and modify female 
pelvic functions. Mental derangements frequently disturb the func- 
tions of several organs of the body, or modify action, healthy or dis- 
eased, in them. Menstrual disturbances are said to be regarded as 
both cause and effect. The greater number of cases of insanity seem 
to arise from conditions and circumstances which depress and exhaust 
the nervous system. In many cases frequent child-bearing and mis- 
carriages, with lactation, cause an excessive drain on the whole body. 
One of the most frequent causes of insanity in women is under such cir- 
cumstances. At the menstrual period is the time women suffer mental 
depression, to a greater or lesser degree. Many cases of insanity, even 
not of reflex cause, are said to suffer worse at the catamenial periods. 

We all recognize insanity at the menopause, called climacteric. 
The most common cause of amenorrhea is impaired general nutrition. 
Most of the anaemic conditions favor menstrual suppression. Mental 
shock and prolonged anxiety so act. Insanity always impairs the gen- 
eral nutrition of the body, and disorders innervation, hence amenor- 
rhea is often the case in the insane. The general health must be built 
up, and the uterine functions restored. 

The uterus and ovaries when diseased, in a patient of a highly 
sensitive organization, may cause mental derangement, which subsides 
only when the causative disease is overcome. The irritation and 
•exhaustion from the pelvic disease may be the exciting cause of insan- 
ity, while the predisposing cause resides either in an altered or a 
deranged nervous system, or in some lesion of the brain, inherited or 
acquired. Sex, in reality, is said to be the predisposing cause of much 
insanity in women. 

The relative frequency of insanity in the two sexes is a subject 
of much observation. Mental disorders are said to be more common 
in women than in men. More females than males are found in the 
asylums of our country, though more females than males recover from 
their first attack of mental aberration. 



Insanity. 167 

It is shown that fifty per cent of all cases of insanity in women 
arise during the discharge of the menstrual function. Depressing 
emotions, or shame and mental distress in the unmarried, vary in dif- 
ferent cases, but the inherited or acquired neuropathic condition is 
fundamental. The exhaustion of nerve force brought about by anaemia 
in puerperal cases, from septic causes, is responsible for puerperal 
insanity. In these cases hereditary tendency is often traced. When 
it manifests itself early in pregnancy, it is considered reflex in many 
cases. 

The menopause, or the change of life, is a most critical period of 
life in a woman's physical relations. At this period of woman's life 
we must not misapprehend the sexual manifestation of insanity. 
Symptoms should not be taken for causes. Perversions of the appe- 
tite are frequently among the premonitory symptoms of this disease, 
and are the essence of all mental aberrations, the sexual instinct being 
no exception to the rule. 

From seventy to eighty per cent, according to statistics, of all 
cases of insanity are curable, if judicious treatment is instituted in the 
first month of the disorder. A longer duration than six months of the 
disease is attended by a rapid decrease in the rate of recoveries. Puer- 
peral insanity furnishes a large per cent of recoveries. 

Treatment. — As insanity is a disease of the whole nervous sys- 
tem, and as the entire physical organization, with every function of the 
body, becomes involved, the system at large must be treated. In all 
cases we are to recognize causes and circumstances depressing and 
exhausting the nervous system. There is no specific treatment. 

Urgent symptoms, as constipation and insomnia, may first need 
attention. A good dose of calomel, followed in ten hours with Rochelle 
salts, is one of the most effective remedies to unload the alimentary 
canal in these cases. To secure sleep, the bromides and chloral hydrate 
produce the most natural. Hvoscin is serviceable, particularly when 
there is excessive motor irritability." When it secures sleep, this change 
indicates the first improvement in the disease. Exhaustion is to be 
guarded against. 

In insanity dependent upon pelvic causes, and in fact in all cases 
of women, a careful inquiry is to be made in reference to existing 
pelvic symptoms and to signs of intra-pelvic affection. In all cases an 
examination should be made by a thorough gynaecologist, in the pres- 
ence of witnesses. The patient may have to be put under an anes- 
thesia before an intra-pelvic examination can be made. Chloroform 
or ether can be administered. 

"The question is, Which disease started first ? Which disease 
seems to be the cause ? Is the case puerperal or climacteric ? Does 
the mental aberration exist independently, or do the two diseases, the 
pelvic and the cerebral, hold any relationship ? This examination 
involves inquiry as to age, the social relation, the menstrual func- 
tion, and the existence of any organic sexual disease. Obscene talk 



168 Insanity. 

upon the part of the patient does not indicate the presence of such 
disease." 

Dr. Shaw recommends the use of nitrous oxide gas for anesthesia 
in these cases. He is the medical director of Kings County Insane 
Asylum, Flatbrush. He has observed no unpleasant effects from its 
use. 

Any pelvic disease which may be the immediate cause of the 
insanity, or the seeming cause, as endometritis, erosions of the cervix, 
chronic pelvic peritonitis, ovaritis, ovarian prolapse, cervical cicatrices 
with uterine displacements and neoplasms, should have special treat- 
ment. Every insane asylum should have on the staff a thorough 
gynaecologist, with experience, and broad, comprehensive views of the 
pathology and treatment of the insane. 

The general management of cases with regard to diet, baths, 
stimulation, medication, how and when to restrain, if necessary, we 
will not mention, especially here, as there is no fixed, machine-like 
treatment adapted to all cases and conditions. 

Treatment, therefore, must be adapted to cases, and the conditions 
and diathesis of each case thus affected, which the physician in attend- 
ance will conduct. 

NYMPHOMANIA. 

"Sexual feeling," says Maudsley (quoted from Keating), "is the 
foundation for the development of the social feeling." Professor 
Keating states upon this subject: "When the sexual feeling in the 
female is excessive or perverted, it is called nymphomania. This form 
of erotomania is a disease in the female like satyriasis in the male. 
There is mental perversion, always attended by uncontrollable sexual 
passion. To gratify the sexual appetite, in advanced and confirmed 
cases, all the decencies and proprieties of life are sacrificed. It is a 
delirium of lust, psychical desire engrafted on a markedly neurotic 
temperament, or a disease excited by impure reading or associations. 
The imagination calls up sexual images, which may lead to hallucina- 
tions and illusions. Nymphomania, in its most severe forms, is asso- 
ciated with, or dependent on, certain varieties of insanity, with or 
without gross brain disease. Although this disease is observed in 
children and in octogenarians, it occurs most frequently at the begin- 
ning or at the end of menstrual life. The genital organs are con- 
stantly in a state of turgescence. There is the greatest perversion of 
the sexual act, gratification being sought by the means of masturbation, 
etc. Thus certain diseases of the uterus and appendages give rise to 
nymphomania. The local exciting causes are intestinal, especially 
rectal, the presence of worms, hemorrhoids, inflammations of the 
urethra and bladder, and diabetic urine. Medicine, even cantharides, 
have very little, if any, such effect. 

"Nymphomania may result from masturbation and sexual causes, 
as well as cause them. Some cases of nymphomania assume a periodic 



Insanity. 169 

form. Sometimes nymphomania is developed from a sudden cessation 
of normal coitus, in women of a highly erotic temperament." 

Treatment. — The best results are obtained by moral suasion, by 
good and thorough occupation, by diversion, and by free physical exer- 
cise in the open air to the point of fatigue, unstimulating diet but very 
nutritious, early rising, cold bathing, regulation of the bowels, the use 
of salt-water enemas to remove rectum worms, followed with sulphur 
ointment inserted with a salve-injector into the rectum, once a day. 
Internal administration of the bromides are the best remedies. The 
galvanic current of electricity will relieve the turgescent condition of 
the genitals. The anode should be placed over the clitoris, and the 
negative over the sacrum, giving from fifteen to forty or more milli- 
amperes, according to the endurance and the strength, little short of 
blistering. Seance from ten minutes to half an hour. This is indeed 
a valuable remedy in some cases. 

The faradic current is not used at all in these cases. The writer 
has treated a few cases of nymphomania with satisfactory results, 
with the galvanic current. The anode is used in the cervix, in the 
vagina, in the rectum, over the clitoris, at or in the beginning of the 
treatment. It takes time and patience on the part of the operator. It 
is better to give two treatments a day at first, until the disease is placed 
under control. Place over the sacrum a broad flat zinc electrode, 
covered with eight or ten thicknesses of surgeon's lint; this is the 
cathode. Place a flat round electrode with a handle covered with at 
least ten thicknesses of surgeon's lint, having first placed over the 
clitoris a small piece of lint or a bit of absorbent cotton dipped in a 
twenty per cent solution of cocain, letting it remain during the seance. 
Place the anode on the clitoris, press very gently, but rather firmly, 
and turn on the current, ten milli amperes at first ; in five minutes 
increase it to thirty, and gradually to fifty, and treat for at least twenty 
minutes. It will give great relief. On alternate days treat the uterus. 
The anode should be applied to the cervix, and the cathode over the 
sacrum. The hemorrhoids should be removed. Treat all local dis- 
eases. Marriage is contra-indicated until a cure has been effected. 
Removal of the ovaries has not given satisfactory results. Very hot 
vaginal douches, 130 degrees to 135 degrees Fahrenheit temperature, 
gives temporary relief, and aids in procuring sleep. Give from ten to 
twenty grains of bromide of sodium, at bedtime, after the hot vaginal 
douche has been given. 

PERVERTED SEXUAL APPETITE. 

Sexual perversion may be either acquired or congenital. It is 
congenital when it arises from defects in the sexual structure, as 
hermaphrodism, or from some defect in the cerebral structure, as in 
idiocy. It is acquired from pregnancy, the menopause, hysteria, 
ovarian disease, or through a stimulation of the nerves of sexual sensi- 



170 Insanity, 

bility from excesses or masturbation. It may be acquired from some 
cerebral disease. Heredity also constitutes an element in causation. 
Insanity is very frequently attended by perverted sexual impulses. 
These sensations may be due to some local disease. They are said to 
be cerebral in origin, existing when the former life has been pure, and 
when there is no local disease. 

DYSPAREUNIA. 

Dyspareunia generally denotes some disease of the vulva, vagina, 
uterus, ovaries, or parametric tissues. While disease of these parts 
generally causes dyspareunia, the opposite state, that of an abnormally 
strong appetite, may result from them. Sexual feelings unknown to 
women until after marriage, may be unduly stimulated. 

Masturbation from erratic desires is sometimes practised by girls 
and women. When it is indulged in, it is, as a rule, the result of some 
local reflex irritation of the sexual or genito-urinary organs. Pruritus 
is a very frequent cause of masturbation in girls and women. The 
habit is formed from scratching, in very young girls. Rectum worms 
create an irritation favoring masturbation. 

The writer had a patient, aged forty-six years, who had not men- 
struated for four months. Suddenly she awoke during the night with 
the most extreme desire for sexual intercourse; previous to this there 
had been no desire. The genital organs were in a turgescent state. 
Hot vaginal douches were administered, which gave relief for two or 
three hours, when the desire returned, causing an hysterical attack. 
Hot vaginal douches were administered every six hours ; bromide of 
sodium in ten to twenty-grain doses was administered every three or 
four hours. The symptoms subsided, but the breasts became suddenly 
very painful and greatly swollen. The turgescent condition of the 
genital organs disappeared when the breasts began to enlarge. I 
inserted a carbon electrode into the vagina, up as near the left ovary as 
possible, it being the negative pole. I placed a flat zinc electrode two 
by three inches , in size, covered with several thicknesses of surgeon's 
lint wet in warm water, over the left breast, corresponding with the neg- 
ative on the left side in the vagina. The faradic current was turned 
on as strong as it could be borne, and the strength gradually increased 
as the current became less contractile, using the primary current of 
electricity. The seance was half an hour. Both breasts and ovaries 
were treated the same. In about ten or twelve hours after the faradic 
current had been thus applied, the menses appeared, and almost a 
uterine hemorrhage followed. The flow continued about three days, 
but not so freely as at the onset. All the symptoms of nymphomania 
subsided, the swelling in the breasts abated, and the menopause resulted. 
The symptoms never returned. 

In case of dyspareunia, painful coitus, we must look for the cause. 
The writer had two cases, due to imperfectly ruptured hymen, which 
were relieved by clipping it in two or three places, and dressing with 
carbolized oil or vaseline. Misplaced uterus, vaginitis, etc., must be 
treated. 



Insanity. 171 

VAGINISMUS. 

Vaginismus is an abnormal contraction of the muscles of the 
pelvic floor. Our first knowledge of this disease we owe to Marion 
Sims. It is considered not a disease, but a symptom of various mor- 
bid conditions of the vulva, the vagina, and the surrounding parts. 
The muscles that form the vagina are abnormally irritable, and reflex 
contraction occurs in them as a result of the following diseases : urethral 
carbuncle, vulvar inflammation, erosions, inflammation, and fissure of 
the hymen, with irritable caruncles, rectal fissures, cervical laceration, 
uterine displacements, as introversions and retroflexions, ovarian pro- 
lapsus, peri-uterine inflammations, and exudations. All these diseases 
are irritated by coitus, and painful coitus results from them. 

Patients who are afflicted with the above diseases are always 
more or less irritable, hysterical, and are often sufferers from neuralgia, 
and easily depressed mentally. There is often a neurotic dysmenor- 
rhea. Vaginismus can be speedily relieved. Sometimes women suf- 
fer for days before applying to a physician for relief, through a sense 
of modesty. 

Treatment. — All attempts at sexual intercourse must be prohibited 
until well of the disease. 

To effect a cure, all local causes are to be removed. An inflamed 
hymen should be excised or exsected, after its being ruptured. The 
patient first having had a hot antiseptic vaginal douche, the caruncle 
myrtiformes are excised, and then dressed with sterilized zinc ointment 
and iodoform gauze, or plain sterilized gauze. Until well, the parts 
must be dressed antiseptically after each passage of urine. The hot 
antiseptic vaginal douche should be taken twice a day, and rest in bed 
is necessary to effect a speedy cure. Some writers recommend stitches 
to be taken after the caruncle myrtiformes are dissected away, and the 
parts dressed with iodoform or aristol, so that the healing may take 
place by primary intention. 

Any irritable fissure of the anus must either be divided with the 
knife or thoroughly dilated under an anesthetic. Keep the anus 
dressed with sterilized linseed oil with a few drops of turpentine spirits 
in each ounce of the oil. This will soon heal the parts. 

Vulvitis and vaginitis yield readily to hot antiseptic vaginal 
douches. Either use corrosive sublimate 1 to 3000, or carbolic acid 1 
to 40, or sulphurous acid one dram to one and a half ounces of warm 
water, to wet the parts after having washed the vagina with a hot 
douche. Retain the sulphurous lotion for about five or more minutes, 
then apply sterilized vaseline with oxide of zinc, two drams of zinc to 
one ounce of vaseline. This ointment spread on antiseptic gauze, and 
placed around the uterus, and spread down the vaginal wall to the 
ostium-vaginse, serves to keep the walls apart. This dressing should be 
removed every morning, and another dressing of the same applied, 
after, of course, a hot vaginal douche being given. 



172 Insanity. 

In chronic cases, where there are erosions of any of the dis- 
eased parts, a topical application of nitrate of silver, from ten to twenty 
grains to an ounce of water, administered once a day after the vaginal 
wash and followed with the oxide of zinc ointment dressing, will soon 
give relief. In some instances an application of a five to ten per cent 
solution of cocaine may have to be applied for eight or ten minutes 
before the vagina is dilated for treatment. It is better to use cocaine, 
so as to be able to treat the parts thoroughly for the first two or three 
times, after which the patient will be so much improved that treat- 
ments can be given without pain. The general health should be looked 
after. Tonics are useful in all the cases. Cod-liver oil should be 
given in cases where women are of consumptive tendencies. 

Cervical lacerations belong to the care of a good gynaecologist. 
Displaced uterus, as retroversions and retroflexions, ovarian prolapsus, 
tumors, etc., belong to the domain of gynaecological surgery. We will 
not go into the details of the treatment of these diseases. However, 
the writer will say that she is opposed to oophorectomy, until all other 
means have been applied, as the galvanic current of electricity has 
relieved, and does relieve, ovarian diseases. Ovarian cysts and can- 
cers call for an operation, but many fibroids are relieved by the use 
of the galvanic current. The cancerous growths of the uterus are not 
specially relieved from pain for any length of time. An operation is 
called for early in the course of the disease, or the patient may suc- 
cumb early after an operation. 

According to medical history, oophorectomy has been greatly 
abused. There has been mistaken diagnosis. This operation has been 
performed for hysteria, menstrual epilepsy, nymphomania, chorea, 
the various forms of insanity, dysmenorrhcea, and pelvic pains inde- 
scribable and ill-defined in character and position. The actual con j 
dition of the ovary, unfortunately, has not always been accurately 
determined. C. D. Palmer, M. D., contends that oophorectomy has 
been more abused than any other operation in the domain of gynaecolog- 
ical surgery, because resorted to for ill-defined symptoms which were 
not altogether dependent upon ovarian functional activity or disease. 
When there is no organic change in the ovaries, and has never been 
any, oophorectomy is almost always contra-indicated. Cystic changes 
in these organs are very common. We should not be deceived by their 
appearance. That a recovery follows oophorectomy, proves only that 
the patient has survived the operation; it does not prove that she has 
recovered from the disease for which the operation was performed. 
Hundreds, if not thousands, of women have had their ovaries needlessly 
sacrificed. Doleris, several years ago, said that in four out of five of 
all cases done in Paris, the operation was unnecessary. More careful 
consideration and a well-rounded treatment for women would save 
numbers of ovaries and tubes. Pain and dysmenorrhea are not suffi- 
cient indications for female castration. 



Insanity. 173 

Many symptoms supposed to be due to organic changes in the 
ovary, are due to obscure perioophoritis or to ovarian neuralgia. 
Oophorectomy is a comparatively safe surgical procedure. When 
properly done, in selected cases, relief is sometimes very speedy; but 
in other cases, this may not be experienced for a year or more. 
Necessity is the only justification of ovarian extirpation. 



CHAPTEE IX. 
THE FEMALE UKETHRA AND ITS DISEASES. 

Anatomy. — "The female urethra is about an inch and a half in 
length, and about a quarter of an inch in diameter, but very dilatable. 
It is widest at the neck of the bladder, narrowing as it passes through 
the sub-pubic fascia or triangular ligament in relation to the compressor 
urethral muscle. Its course is curved upwards and backwards from 
the meatus." 

The urethra is separated from the vagina by an intermediate layer 
of cellular tissue. 

The inferior opening of the urethra, the meatus-urinarius, is 
situated on the median line at the lower margin of the vestibule, its 
posterior or superior orifice at the neck of the bladder. The urethra, 
when at rest, is a closed tube. 

URETHRITIS. 

Simple urethritis is frequently met with. It may occur from a 
variety of causes. In a large number of cases it is gonorrhoeal in origin. 

SIMPLE URETHRITIS. 

The irritating effects of concentrated urine, especially alkaline 
urine, is very frequently met with among women at or about the meno- 
pause. Septic vaginal discharge, or in case of gonorrhoea, chemical 
irritants, and mechanical injuries, catarrh of the bladder and urethra, 
are among the causes. Prolonged and unsatisfied sexual excitement 
will produce urethritis. In the specific form of gonorrhoeal origin, 
the period of incubation is from two to iive days. 

Symptoms. — Urethritis usually begins with a slight chill in 
sensitive patients, but not always. Eor several days there is malaise, 
and moderate burning and tickling upon urinating. These symptoms 
are often overlooked. The prominent symptoms in the acute stage are 
painful urination. Scalding and burning caused by the passage of the 
urine over the inflamed surface of the urethral canal is complained 
of; there is a frequent desire to urinate, and often only a few drops 
of urine can be passed; sometimes a few drops of blood escape after 
micturition, or may pass with the urine. Hemorrhage from other 
portions of the urinary tract is usually more intimately mixed than 
when it proceeds from the urethra. 

The milder form of urethritis, not septic or non-specific, usually 
runs its course in a few days. The gonorrhoeal form lasts from five 

(174) 



The Female Urethra and Its Diseases. 175 

to six weeks, the acute symptoms subsiding in from ten to fourteen 
days. 

Diagnosis. — In acute urethritis, the meatus is swollen, reddened, 
and the urethral mucous membrane is a little prolapsed, exposing the 
inflamed orifice of the urethral glands. The urethra is felt, per 
vagina, as a firm cord, and tender to the touch. From pressure through 
the vagina upon the urethra from above downwards, a purulent fluid 
can be pressed out from the meatus. If the patient voids the urine, a 
portion of it into one vessel, and the remainder into another vessel, dur- 
ing the acute stage, cloudy urine will be found in the first vessel, clear 
urine in the second. Cloudiness of the second urine indicates cystitis. 

In women gonorrheal urethritis frequently passes into the chronic 
stage. Very frequently before urinating a drop of thin, milky muco- 
pus may be pressed out of the urethra, per vagina, pressing from 
behind forward. 

Treatment. — The treatment consists in rest, a non-stimulating 
diet, the use of alkaline drinks, hot vaginal douches, and saline lax- 
atives. In the subacute and chronic stages, the oil of sandalwood, ten 
to five minims every four hours, to be taken on sugar or in capsules. 
It is a good plan to take it in flaxseed tea. A large wineglassful of 
the tea is a sufficient amount. Salol agrees with the patient some- 
times better than the sandalwood. The dose of salol is five grains 
every three or four hours. 

There are different opinions as to the proper time to begin wash- 
ing out the bladder. Some writers recommend waiting until pain and 
smarting have nearly ceased. Others advise washing out the bladder 
at the onset of an acute case. This depends upon the general condi- 
tion of the patient. Some patients are too nervous, and unable to 
bear pain, while others can bear sufficient pain to have the bladder 
washed out. 

For urethral injections, Neiser, Guy on, and others employ injec- 
tions of nitrate of silver, 1 to 400*0, repeated from four to six times 
daily. During convalescence the frequency is reduced to once a day. 
"For the first few days after beginning this treatment," says Neisser, 
"the discharge is increased ; it then becomes watery, and contains more 
epithelium, the gonococci rapidly disappearing. The injections are 
made when the bladder is moderately full, with an ordinary urethral 
syringe, a pipette, or Skene's reflux catheter, which is adapted to 
urethral irrigation. The bladder should always contain urine in 
order to prevent direct action of the injected fluid upon the wall of 
that organ." Irrigate the bladder with a warm solution of boracic 
acid, ten to twenty grains to the ounce, retain it a few minutes, and 
then let the patient void the bladder. Now apply a six per cent solu- 
tion of cocaine to the urethral canal, through an endoscope or a urethral 
speculum, for about five or more minutes; then apply a solution of 
cupri-sulphas — ss gr. to the ounce of water — to the urethra. About 
three treatments in twenty-four hours is often enough to use the cupri- 



176 The Female Urethra and Its Diseases. 

sulphas. Hot vaginal douches are very necessary, to be given. each 
time before the bladder is washed with the boracic solution; also let 
a stream of hot water pass over the urethra for a few minutes after the 
vaginal douche is administered. Oxide of zinc ointment, applied to 
the inner surfaces of the labia after the urethral treatment, is very 
soothing to the affected parts. 

A milk diet is very essential in all cases of urethritis. One 
to two ounces of the infusion of buchu, with the sandalwood and flax- 
seed tea, is very useful in these cases. 

STRICTURES OF THE UKETHKA. 

The treatment of stricture belongs to surgery. However, the 
galvanic current of electricity, the cathode being used in the urethral 
canal, will soon dissolve any cicatricial tissue. Seance once or twice 
a week. Cocaine the urethral canal, wash out the bladder with boracic- 
acid solution, ten to twenty grains to the ounce ; then apply the galvanic 
current with a uterine electrode, or with a urethral electrode to fit the 
canal. The anode is placed in the vagina. Give from five to ten milli- 
amperes. Seance three to five minutes ; in some cases give ten min- 
utes, according to the thickening of the urethral canal. The causes of 
cicatricial contraction are chronic -urethritis, most frequently gonor- 
rheal; injuries during childbirth, and other forms of traumatisms; 
caustic applications, and syphilitic and tuberculosis ulcers. Atresia 
may arise from atrophy of the muscular coats of the urethra. 

Symptoms. — Irritability of the bladder and dysuria are usually 
most prominent symptoms. Occasionally there is incontinence of the 
urine, or partial retention, which may give rise to cystitis. 

Diagnosis. — Digital examination per vagina will reveal the thick- 
ened condition of the urethral canal. A sound passed into the urethra 
will reveal the extent of the stricture and the location. Any obstruc- 
tion by pelvic neoplasms from pressure upon the urethra can be readily 
distinguished from cicatricial contraction. 

Treatment. — Gradual dilatation, as practised in the stricture of 
the male urethra, which often demands surgical procedure. 

PROEAPSE OF THE URETHRAL MUCOUS MEMBRANE. 

Hoffmeir observes that this affection is most frequently met with 
in young debilitated women and children. It is said by writers that 
the process of eversion is usually a gradual one. Acute prolapse is, 
however, possible. The prolapse generally involves the entire margin 
of the meatus. In recent prolapse the surface of the tumor differs 
little in appearance from the normal mucous membrane. In long- 
standing cases the protruding mass may become dark, edematous, fis- 
sured, eroded. 

Hoffmeir mentions two cases which occurred in children seven 
and nine years of age. Sodermark has reported three cases, two of 



The Female Urethra and Its Diseases. 177 

which occurred in old women, aged fifty-eight and seventy years respect- 
ively. The third one was found in a child of nine years. 

Etiology. — Age and debility favor its development. In children 
violent and prolonged coughing is regarded as the exciting cause. 

Symptoms. — There is a straining sensation, or vesical tenesmus 
and dysuria are marked in proportion to the degree of the obstruction 
and the sensitiveness and the irritability of the urethra and the dis- 
placed structures. Soreness and pain are increased on walking, and 
coitus is frequently painful. Pain, however, is not always present, 
especially in children. 

Diagnosis. — When the displaced mucous membrane is not too much 
strangulated and swollen, mere prolapse may be distinguished from new 
growth by the fact that it may be replaced. Again, urethral prolapse 
generally appears as a circular protrusion, with a central opening. 
The tumor is a less vivid color, is less prone to bleed, and is less sensi- 
tive to the touch than a caruncle. 

Treatment. — In recent cases, and in others in which the prolapsed 
structures are in a comparatively healthy condition, simple measures 
may be tried. The protruding mass should be replaced, after reduc- 
ing the swelling by the application of hot water or ice. After reposit- 
ing the redundant mucous membrane, retraction of the urethral canal 
is to be promoted by the use of suitable applications, such as touching 
daily with a two per cent carbolic acid solution or a dilute tincture of 
iodine. Tannic acid bougies, weak solution of persulphate of iron, 
or other astringent remedies, may be tried. Meantime the patient 
must be left in a recumbent posture, and care used to guard against 
a recurrence of the prolapse during micturition. Vesical or rectal 
tenesmus or straining, so far as possible, must be relieved. The blad- 
der should be examined for stone or vesical tumors. If these means 
fail to relieve the condition, more active measures will have to be 
resorted to. Some writers (Jewet and Pollok) have succeeded with 
linear cauterization of the prolapsed membranes. Erosion of the 
redundant tissue is frequently necessary. A good gynaecologist should 
have the care of these cases. 

VESICO-URETHRAE FISSURE. 

"Skene says that this lesion is by no means infrequently met with 
in the female. About two-thirds of the fissure is located in the urethra, 
while only the upper portion extends into the vesical neck; yet the 
entire lesion is within the grasp of the sphincter-vaginae, in the majoritv 
of cases, and is then a potent cause of irritable bladder, which may 
often pass unrecognized by the physician. The cause may probably 
lie in a previous urethritis. Injuries during childbirth favor develop- 
ment of urethral fissures." 

Symptoms. — The symptoms depend upon its site. Occurring, as 
it does, at the union of the bladder and the urethra, and because of the 



178 The Female Urethra and Its Diseases. 

constant slight pressure of sphincteric contraction, the pain is contin- 
uous and severe. The upper portion of the fissure, which extends into 
the bladder, is exposed to the irritation of the urine, and excites a 
constant burning pain at the neck of the bladder. Pain is most severe 
during and after urination, and the patient strains to empty the blad- 
der. Occasionally a few drops of blood escape at the end of micturi- 
tion. The pain varies in degree, in some cases being intense when the 
urine is highly acid, and less severe when it is neutral or alkaline. 

Diagnosis. — Pressure with the fingers upon the neck of the blad- 
der and posterior urethra produces a sensation as though a knife were 
piercing the part. 

The symptoms of cystitis and urethritis very closely simulate those 
of urethro-vesical fissure. In fissure, the pain is acute and circum- 
scribed, while in cystitis it is diffuse and frequently extends over the 
body of the bladder. In cystitis a sense of relief soon follows mic- 
turition, in urethritis the greatest pain occurs during micturition, and 
subsides shortly after the bladder is emptied. Examination of the 
urine will exclude cystitis, while the presence of fissure can be detected 
and urethritis excluded by careful endoscopic examination. In a 
majority of cases observed by Skene, he has found the fissure on the 
right side of the neck of the bladder -anteriorly. He states: "Through 
the endoscope, with the parts on the stretch, it appears as freshly torn 
and bleeding, from one-fourth to one-half inch in length, and from 
one-twelfth to one-sixth inch in width, tapering toward the ends. The 
deepest part has a gray color, like an indolent ulcer, while the edges 
appear actively inflamed." 

Treatment. — This is considered one of the most troublesome 
affections of the urinary tract which the surgeon is called upon to 
treat. 

Skene recommends touching the fissure with galvano-cautery. 
The knife and argent nitrate in the mitigated stick are applied by 
drawing them through the ulcer in a similar manner as through the 
fenestra of the endoscope. 

When these methods fail, the establishment of a vesico-vaginal 
fistula, placing the fissure at rest, offers the only chance of recovery. 

URETHROCELE. 

The etiology of urethrocele is not settled. Injuries at childbirth 
are seemingly responsible for this condition met with in women, as it 
is most commonly met with in women who have borne children. 
According to English, the divertular form results from the rupture of a 
congenital cyst of the urethral wall into the urethral canal. 

Symptoms. — The symptoms of urethrocele are for the most part 
due, directly or indirectly, to the retention of a certain amount of urine 
in the sac. The residual urine becomes ammoniacal by decomposition, 
and finally purulent. The sac wall becomes inflamed and eroded. 



The Female Urethra and Its Diseases. 179 

The ammoniacal urine will cause cystitis, also urethritis. Cystitis 
sometimes results from extension into the bladder. In many cases 
decomposed urine is expelled from the sac by sneezing or coughing or 
laughing, or any sudden muscular effort, giving rise to severe and 
troublesome excoriations of the surrounding external surfaces. There 
is frequent desire to urinate, and urination is painful. 

Diagnosis. — To examine per vagina, the sac is perceptible to the 
touch, and to ocular inspection of the anterior vaginal wall. When the 
pouch is of large size, it protrudes from the vulva. The retention of 
the urine may be demonstrated by drawing it off with a catheter. 
Under pressure with the finger the sac collapses, and the contents ooze 
from the meatus. The passing of a curved sound into the pocket per 
urethram demonstrates the existence of the sac or pouch. 

Skene advises operation by making a fistulous opening, the whole 
sac being excised. The fistula may be closed after the parts have been 
treated and restored to a normal condition. If cystitis is present, it 
is to be treated as in other cases. In some cases of urethrocele Skene 
advises dilating the lower part of the urethra, and supporting the sac- 
culated portion either with a pessary or with a tampon, together with 
the use of the usual topical applications. 

URETHRAL DISLOCATIONS. 

The only urethral dislocations of importance are the downward 
displacements. Upward dislocation is said, as a rule, to give no symp- 
toms, save the diffiulty in passing the catheter. In downward dis- 
placements varying degrees of suffering are complained of by the 
patient. The displacement may be partial or complete. In partial 
dislocation downward the upper two-thirds of the urethra is prolapsed, 
that portion of the canal having a backward instead of an upward direc- 
tion. When the prolapse is complete, the bladder appears at the 
vulva, with the urethra protruding between the labia minora. 

Etiology. — Downward dislocation of the urethra is associated with 
prolapse of the anterior wall of the vagina. These conditions are 
almost uniformly the result of injuries during childbirth, sagging of 
the anterior vaginal wall occurring in perineal lacerations, involving 
the levator-ani muscles. The bladder, or the upper portion of the 
urethra, is then permitted to fall below its normal position. 

Symptoms. — In minor degrees of displacement there is vesical 
irritability and partial loss of control of the bladder ; urine escapes on 
coughing, sneezing, or laughing. In extreme displacements this 
unpleasant condition or symptom is absent. The sharp bend in the 
urethra prevents incontinence, and difficult urination is the rule. The 
severity of the symptom is much relieved by the recumbent position. 

Diagnosis. — The diagnosis is easily made by a digital examination 
per vaginam, or by inspection with or without the aid of a speculum. 

Treatment. — Perineal injuries should be repaired. Temporary 
relief, with some degree of permanent benefit, may be gained by the 



180 The Female Urethra and Its Diseases. 

use of vaginal tampons, or the use of a pessary so constructed as to sup- 
port the entire prolapsed wall or portion of the urethra. 

FISTULAE. 

"Urethral fistulse may be complete or incomplete ; both forms are 
of rare occurrence." 

Complete fistula opens into the vagina. Fistulas result from 
injuries during childbirth. They give rise to comparatively little 
inconvenience, as the urine passes through the fistula only during mic- 
turition. 

* Incomplete urethral fistula is an opening leading from the urethra 
into the urethro-vaginal septum, and ending in a blind extremity. A 
peri-urethral abscess rupturing into the urethra may leave such a 
fistulous tract. 

Diagnosis. — Pain during urination and a sense of heat in the 
urethra are common symptoms. A blind fistula in the posterior por- 
tion of the canal, in the vicinity of the vesical neck, gives rise to a fre- 
quent micturition and tenesmus, or straining. Pus may at times ooze 
from the urethra. Smarting during and for some time after urina- 
tion is almost always present. 

Treatment. — The fistula should -be closed by means of operative 
procedure. The fistula is first made complete and the edge of the 
wound carefully denuded. The urethra and the fistulous tract are then 
to be kept clean by injections into the urethra of a solution of boric 
acid, or some other equally bland antiseptic. The urine is drawn with 
a catheter, to prevent irritating the wound. Then the urethro-vaginal 
fistula may close of its own accord, or it can readily be closed by the 
usual operative procedure. 

URETHRAL TUMORS. 

Caruncle. — Caruncle is a small, raspberry-like growth at the 
external orifice of the urethra. It is situated, most usually, at the 
inferior or posterior portion of the meatus, though it may spring from 
any part of the circumference. In exceptional cases its location is 
above the orifice within the canal. These growths vary in size from that 
of a pin-head to that of a split pea, and are usually single, though occa- 
sionally multiple. They consist of hypertrophied papilla?, and are 
extremely vascular and abundantly supplied with nerve filaments. 

Symptoms. — The most prominent symptoms of urethral caruncle 
are great sensitiveness to touch, and often extreme pain during micturi- 
tion. The severity of the symptoms seems to be out of proportion to 
the apparent importance of the lesion. Sexual intercourse is very 
painful, often impossible, owing to the reflex spasm of the levator-ani 
muscle. There is irritation of the bladder, giving rise to a frequent 
desire to urinate and to vesical spasm. In extreme cases cystitis may 
result. There is usually more or less hemorrhage from the tumor. 
This affection of the urinary tract gives rise to more serious injury to 



The Female Urethra and Its Diseases. 181 

the general health. In neglected cases the nervous system is shattered 
by pain and loss of sleep, and the patient is reduced to a condition of 
chronic invalidism. 

Diagnosis. — Caruncle must be distinguished from urethral polypi 
and from prolapse of the urethral mucous membrane. A polypus is 
usually attached by a slender pedicle, "while in papillary angioma the 
growth is sessile." The former lacks the sensitiveness of the latter. 
In prolapse the protrusion is circular, with the urethral orifice at its 
center, while caruncle springs from a portion only of the circumference. 
The vascular tumor can not be reduced. Angiomata, affecting the 
deeper portions of the urethra, may be differentiated from other ure- 
thral tumors by their sensitiveness to touch with the probe, or to the 
pressure of the fingers through the urethro-vaginal septum. 

VARICES. 

Varicose veins appear as a bundle of irregular, distended, dark- 
blue, or bluish-red vessels, most frequently occupying the urethral floor. 

GLANDULAR NEOPLASMS. 

Urethral cysts may be located in any point in the canal. In early 
life they occur in the meatal portion, later, near the vesical neck. 
Their origin is due, for the most part, to occlusion of the orifice of 
urethral glands. These small cysts are transformed into polypi by the 
absorption of their contents. 

FIBROMA AND SARCOMA. 

The former, as a rule, lies embedded in the muscular wall of the 
urethra. It is frequently peduncular, and protrudes from the meatus. 
In size fibromata vary from the bulk of a pea to that of a goose-egg. 

Sarcoma of the urethra is so seldom met with that its mere men- 
tion in this connection will suffice^ 

CARCINOMA AND EPITHELIOMA. 

The existence of primary cancer of the urethra is very rare. It is 
less frequent in the female than in the male. 

POLYPUS. 

True polypus is a rare occurrence. It springs from a high point 
up in the urethral canal. Polypi are not painful, but cause obstruc- 
tion to micturition. 

Treatment of Caruncle. — The chemical caustics are unsatisfactory. 
The growth, as a rule, soon returns. Complete extirpation is the treat- 
ment for permanent relief. This is done by extirpating the growth 
with actual cautery. Some operators excise the diseased structures 
and stitch the edges of the healthy mucous membranes of the urethra 
together. Skene recommends the use of the galvano-cautery, as fol- 



182 The Female Urethra and Its Diseases. 

lows: "The neoplasm or caruncle is seized by a narrow-bladed forceps 
at the junction of the normal and abnormal tissues; the forceps are 
closed and locked, and the caruncle cut off. The cautery is then 
applied to the forceps sufficiently to heat hot enough to desiccate but 
not char the tissues held in their grasp. This being accomplished, 
the forceps are carefully removed, by first unlocking, then rocking them 
gently, so as not to pull the pedicle or stump apart and start bleeding. 
If the work is well done, the thin stump of desiccated tissue will project 
on the surface of the mucous membrane. The bladder should be 
emptied before operation, so that there will be no necessity to urinate 
fdr five or six hours after. This lessens the danger of reopening the 
stump ; and usually but a small linear surface is left to heal by granu- 
lation after the eschar sloughs. Applications of sterilized vaseline 
help to protect the stump while healing. " 

When a neoplasm or caruncle arises from Skene's glands, which 
are two glandular tubes situated just within the external orifice of the 
urethra, which were first discovered by Skene, he says: "Upon each 
side, near the floor of the female urethra, there are two tubules large 
enough to admit a No. 1 probe of French scale. They extend from 
the meatus-urinarium upward, from^ three-eighths of an inch to three- 
fourths of an inch, running parallel with the long axis of the canal. 
They are located beneath the mucous membrane, in the muscular walls 
of the urethra. The mouths of these tubules are found upon the free 
surface of the mucosa, within the labia of the meatus-urinarius." 

For these glands (Skene's) the best method of treatment is to pass 
a fine probe up into the canal, and cut down upon it with a fine cautery 
point from the vaginal surface. In other words, lay the ducts of the 
glands open. This divides the neoplasm on one side, and an incision 
should be made with the cautery on the opposite side, which divides 
the growth into two equal parts, when each part is grasped with the 
forceps, and removed as already described. 

Treatment of Other Urethral Tumors. — Tumors of a broad base 
are readily removed by the ligature. The growth being exposed and 
drawn into reach with a pair of forceps, the base is transfixed with 
a needle from without inward, in a direction parallel to the axis of the 
canal ; a ligature is then thrown around the base beneath the transfixed 
needle, traction being made upon the tumor with the forceps to bring 
the sides of the base into the grasp of the ligature, which is then tied 
tightly, care being taken to prevent cutting the tissues in the ligature. 
Torsion, or twisting, is also applicable in pedunculated neoplasms. 
The base of the pedicle is seized with small, thin-pointed forceps, and 
the growth is twisted off with an ordinary pair of nasal forceps ; then, 
as a preventive against hemorrhage, touch the stump of the pedicle 
with the galvano-cautery. 

The Germans employ the curette for the removal of growths high 
up in the urethra. After they curette, the site of the tumor is to be 



The Female Urethra and Its Diseases. 183 

dried up and seared with the cautery. Skene uses a polypus snare 
for the removal of growths high up in the canal. 

The galvanic current of electricity applied to the stump of the 
neoplasms after removal acts beneficially. Cocaine the pedicle, place 
several thicknesses of surgeon's lint, about three-fourths of an inch in 
width, dipped into some kind of bland antiseptic solution, over the 
pedicle; then place the anode of the proper size on the lint, and place 
the cathode over the hypogastric region. Give from ten to twenty mil- 
liamperes for twenty minutes, which will prevent bleeding and hasten 
the absorption of the pedicle. The first application of galvanism is 
made the third day after the neoplasm or polyp has been removed. 
An ointment of sterilized vaseline, with iodoform or oxide of zinc oint- 
ment, is used for dressing. 

The writer has successfully removed neoplasms with an electric 
needle. The anode is used at the base of the caruncle, or neoplasm, 
and the cathode is applied through the apex, or on the top, just under- 
neath the second layer of the mucous membrane. Cocaine, ten to twenty 
per cent solution, is applied until the affected part can be punctured 
without pain ; then the neoplasm is grasped with forceps, and the plat- 
inum needle is passed through the base, or just barely underneath the 
base, of the growth, while from time to time cocaine is being dropped 
on the parts being treated. The forceps are now removed, and the 
needle attached to the negative pole and passed through the apex. 
The current is turned on very slowly, until the pathological sign is 
visible, that is, when the neoplasm at the base begins to have a blanched 
appearance. Sometimes five to ten milliamperes are sufficient, accord- 
ing to the age and size of the caruncle, and whether it is of a compli- 
cated nature; in the latter case it may take fifteen to twenty milli- 
amperes. As soon as the mucous membrane shows a blanched appear- 
ance, the current is sufficiently strong to destroy the growth, and this 
must be the guide to determine the number of milliamperes to be given. 
Give from a half minute to a minute ; now reverse the current for a 
few moments, and remove the needle. Apply the needle on the oppo- 
site side the same as the first. Treat every portion of the caruncle 
until every blood-vessel has a congealed and blanched appearance. This 
must be done with care and judgment, that it may not be overdone. 
After the seance apply sterilized vaseline. When the patient voids 
the bladder, the parts must be washed with clean boiled water, and 
the dressing of the vaseline applied. Usually one treatment thus 
given is all that is necessary for the removal of the growth. It usually 
takes two or three weeks for the neoplasm to disappear after the treat- 
ment. The patient should rest in bed for at least three days after the 
galvanic treatment. Very often, however, patients will not rest at all 
after the treatment, as they feel no inconvenience from it. When they 
will not rest, but keep on their feet as usual, a second treatment may 
have to be given, and it is well to make known the fact. 



184 The Female Urethra and Its Diseases. 

FOREIGN BODIES IN THE URETHRA. 

Foreign bodies of various descriptions may find lodgment in the 
urethra. 

# Partial retention of the urine is the chief symptom. It may be 
a stone lodged in the urethra, or it may be from a wound. 

Diagnosis. — Diagnosis is made through the vagina, with the index 
finger, while examining the urethra. 

Treatment. — "Treatment is by extracting the foreign substance 
with a pair of long, thin-bladed forceps. The body is held in place 
by the finger in the vagina, pressed against the urethra at a point imme- 
diately behind the body during the attempt to engage it in the forceps. 
Sometimes a wire loop or a smooth curette is used for the purpose of 
removing foreign bodies from the urethra. If this be impracticable, 
incision of the urethra at the point of obstruction may have to be 
resorted to." > 



CHAPTEK X. 
DISEASES OE THE BLADDER. 

Anatomy. — The ligaments of the bladder, which are found by the 
reflections of the peritoneus and the expansions of the pelvic fascia, 
are of the greatest importance, as they serve to maintain the position 
of the neck of the bladder. The bladder is a hollow, muscular organ. 
When empty, or moderately filled, it lies entirely below the plane of 
the pelvic brim, between the pubic bones in front and the vagina behind. 
In the infant it is an abdominal organ, and is somewhat pear shaped. 
In old age there is a partial return to infantile conditions. When 
the bladder is over distended, it rises above the line of the pubic bones, 
and is seen as a mesial projection above the symphysis. In extreme 
cases it may reach the umbilicus, it being more distensible in the female 
than in the male. . 

The bladder has three openings, — the ostrum urethra-internum 
and the two ureteric orifices. The ureteric orifices are situated one on 
each side of the median line, on the floor of the bladder, about three 
centimeters behind the vesical opening of the urethra, and the same 
distance apart. A transverse band stretching from one side to the 
other is known as the inter-uteric ligament. 

Kelley says : "The appearances of the urethral orifice differ in dif- 
ferent cases. It sometimes appears as a dimple, or as a fine slit in the 
mucous membrane ; at other times as a V. with, the point directed out- 
wards. Again, it may present the form of a truncated cone, with gently 
sloping sides, the urethral mons." 

The regional divisions of the .bladder are "the apex, or summit ; 
the base, or inferior fundus ; and the so-called neck." The summit of 
the bladder is upward and forward, and is attached to the urachus. 
The base is the part which looks downward and backward. The trigon 
is a triangular space at the base of the bladder, whose apex is at the 
urethral orifice, and whose base is in the interior line. Over this the 
mucous membrane is thinner and more closely adherent, having no 
sub-mucous layers. The nerve supply to this space is very abundant, 
and it is accordingly the most sensitive area of the bladder. The apex 
of the trigon, where it merges into the urethra, is the so-called vesical 
neck. In that part of the base which lies just behind the inter-uteric 
line is a slight depression, the bas-fond. which in old age becomes a 
deep pouch holding residual urine. 

The more important anatomical relations of the bladder are of a 
clinical interest. In the erect posture the anterior inferior surface 

(185) 



186 Diseases of the Bladder. 

looks toward the symphysis. It is separated from the pubic bones by a 
space known as the cavum Retzii. This space contains a variable 
quantity of loose fat. Each lateral surface is partially covered with 
peritoneum. The posterior surface is intimately connected below the 
cervix-uteri, and to the upper part of the anterior wall of the vagina, 
but is separated above from the body of the uterus by the shallow fold 
of the peritoneum, the utero-vesical pouch. The superior surface lies 
in contact with the small intestines, sometimes also with a portion of 
the sigmoid flexure and with the appendix vermiformis. 

The ligaments of the bladder are five false and five true ligaments. 
The false ligaments are formed of folds of peritoneum ; this is reflected 
from the inner face of the anterior abdominal wall at a point just above 
the symphysis to the bladder, investing that organ, as has already been 
shown, superiorly, laterally, and, in part, posteriorly. It joins the 
bladder in front, dipping down over the superior vesical surface, and 
passes as far backward as the point of contact between the vesical base 
and the uterus at the junction of the uterine body and cervix. The 
superior peritoneal fold in front, which extends from the summit of 
the bladder to the umbilicus, covering the urachus, two utero-vesical 
folds, and two lateral folds of peritoneum, constitutes the false liga- 
ments. The true ligaments of the bladder are superior (the urachus), 
two lateral, two vesico-pubic, the last four being formed at the recto- 
vesical fascia. 

The bladder has three coats, a mucous, a muscular, and, over a part 
of its surface, a serous or peritoneal coat, the relation of which to the 
viscus has already been described. The muscular coat consists of three 
layers, but the innermost is incomplete. The fibers run, for the most 
part, in longitudinal and in circular directions ; at the neck the circular 
fibers are collected into a layer of some thickness, which immediately 
surrounds the upper end of the urethra, forming the so-called sphincter- 
vesicse of some writers. The mucous membrane is lined by transition- 
stratified epithelium, and is arranged in irregular folds. Throughout 
the mucous membrane are minute glands and follicles. 

The vascular supply of the bladder is derived from the superior, 
middle, and inferior vesical arteries, and from branches of the uterine, 
internal, pubic, hemorrhoidal, and sciatica. The veins form tortuous 
plexus about the base, sides, and neck, and finally empty into the inter- 
nal iliac veins. The lymphatic distributions in the submucous cellular 
tissues of the bladder are quite extensive, the lymphatic vessels empty- 
ing into the hypogastric glands. 

The nerves of the bladder are derived from the third, fourth, and, 
in rare cases, the second sacral nerves of the spinal system, and from 
the hypogastric plexus of the sympathetic. The latter plexus is situ- 
ated in front of the last lumbar and first sacral vertebrae. The branches 
of the spinal nerves go mainly to the base, and not to the neck, of the 
bladder. 



Diseases of the Bladder. 187 

MALFORMATIONS OF THE BLADDER. 

Congenital defects of the bladder, though of great variety, are of 
rare occurrence. 

Fissure of the bladder is the most common congenital defect of 
that organ. It is said to be far more frequent in the male than in the 
female subject, eighty to ninety per cent of such cases occurring in the 
former sex. It is associated with partial failure in the closure of the 
ventral-laminae. It consists in a cleft, often the entire absence of the 
anterior wall of the bladder, and a median fissure of the anterior 
abdominal wall. Like other anomalies of development, it is rarely 
single. Frequently the urethra and the vagina are absent. Mal- 
formations of the vagina or uterus and developmental defects of other 
pelvic organs, and even harelip and spina bifida, are not uncommonly 
found associated with this anomaly. The ventrical cleft may be limited 
to the region of the umbilicus, to the symphysis, or may involve the 
entire inferior half of the anterior abdominal parietes. When the 
ventral fissure is situated near the umbilicus, the pubic symphysis is 
closed, and the urethra, the inferior portion of the bladder, and the 
external sexual organs are normally developed. Fissure limited to the 
lower part of the bladder, or the corresponding part of the pelvis, is 
very seldom found. 

When the malformation involves the lower portion of the abdom- 
inal parietes, there is usually separation of the pubic bones, the clitoris 
is cleft or undeveloped, the urethra, and possibly the vagina, are absent. 
The posterior bladder wall is pushed forward, and protrudes into the 
abdominal wall. The latter condition is known as exstrophy of the 
bladder. The exposed mucous membrane is inflamed and swollen. 
The urethral orifice is usually exposed to view. The ureters are gen- 
erally enlarged, sometimes having a diameter of two, or even eight or 
ten, centimeters, and their pelvic course and relations are altered. 
The exposed vesical mucosa of the posterior wall may take on, to some 
extent, the appearance of the epidermis. The urethra is either imper- 
vious or, more frequently, entirely absent. 

"Treatment of exstrophy of the bladder is surgical. All devices 
thus far proposed for collecting the urine are useless." 

FUNCTIONAL DERANGEMENTS OF THE BLADDER. 

The causes are various. The local disorder may be one of the 
manifestations of a general neurosis. In hysterical, nervous women 
we meet with what is termed irritable bladder, which is so often a 
symptom of disease in other organs. Frequent urinating, inconti- 
nence, and spasmodic retention are often seen in this class of patients, 
from no other cause than disordered innervation. Any influence which 
acts to depress or excite the nervous system may be a contributing 
factor. Vesical irritability is no doubt frequently a result of abuse of 
the sexual functions. 



188 Diseases of the Bladder. 

Violent emotional disturbances are sometimes attended with loss 
of control over the vesical sphincter. This is illustrated in the occa- 
sional effect of severe fright. Examples of the extent to which mental 
influences may affect the bladder are the refusal of the sphincter to 
relax in the presence of another, and of the opposite effect of the sound 
of running water. 

Reflex vesical disorders in many instances are due to urethral 
caruncles, polypi, strictures, tumors, and other diseases, which may 
be the source of the vesical irritation. 

x Painful affection of the vagina and urethral diseases act in a like 
manner. Fissure of the anus, hemorrhoids, stricture of the lower part 
of the rectum, ascarides, and other causes of rectal irritation, are com- 
monly-recognized sources of retention and other disturbances. Inflam- 
matory diseases of the uterus, tubes, ovaries, or pelvic peritoneum 
frequently give rise to irritable bladder. Painful irritability is often 
observed after abdominal operations in which the adjacent viscera have 
been concerned. Greatly increased or diminished density of the urine 
makes it irritating to the bladder; so also does hyperacidity and alka- 
linity. 

Mechanical disturbances, as cystocele, the traction of a misplaced 
uterus upon the vesical neck, or of a tumor to which the bladder is 
attached by adhesions, pressure of a gravid or pregnant uterus, or a 
pelvic neoplasm, are potent causes of vesical disturbance or irritable 
bladder. 

Symptoms. — The symptoms resemble those of cystitis. There is 
dull pain and a sense of weight in the region of the pubes, often increased 
on standing or walking. The pain is felt most at the vesical base and 
neck, the nerve supply being most abundant in this region. 

Urinating is frequently painful and difficult, or sometimes ure- 
thral spasms make it impossible. Hot water or hot fomentations have 
to be employed to relax the spasm before the bladder can be voided. 
When the trouble is due to some morbid condition of the urine, a chem- 
ical test will clear up the diagnosis. 

Diagnosis, — Generally a chemical test and a microscopical exam- 
ination of the urine excludes organic disease ; also the absence of albu- 
men, pus, blood, and excess of vesical epithelium. Simple hyperacidity 
or alkalinity, and extreme concentration or dilution of the urine, are 
significant. Exploration of the bladder by abdomino-palpation, espe- 
cially of the inferior portion of the organ, helps to exclude cystitis and 
foreign bodies. The uterus, ovarian tubes, broad ligaments, the 
urethra, the pudendum, and the rectum must be examined for the rec- 
ognized cause of reflex vesical irritation. All neurotic tendencies must 
be looked into, and taken into account. "If in doubt, a careful cysto- 
scopic examination is conclusive, best by the direct method." — Kelly. 

Treatment. — The cause is to be removed by the means most appli- 
cable to each individual case. A carefully-prescribed and suitable 
hygienic and tonic regimen is very necessary to improve the condition 



Diseases of the Bladder. 189 

of the nervous system. Open air, sun-baths, and a well-regulated sys- 
tem of physical culture are valuable remedial agents in the treatment 
of most nervous women. All bad or injurious habits should be sought 
after and corrected. Tonics of iron and strychnine are especially 
serviceable in toning up the system. Hot vaginal and rectal douches, 
hot sitz-baths, and applications of moist or dry heat to the lower pelvic 
region over the body of the bladder, over the supra-pubic region, over 
the neck of the bladder, are most valuable to relieve pain. The heat 
acts as a sedative. A hot-water bag placed over the seat of pain often 
gives quick relief. Hot fomentations may be first applied and the 
hot-water bag placed over the hot flannel, so as to keep the heat, using 
care not to get the bedclothing wet, which may be done by placing a 
hot towel, folded, over the hot-water bag for protection. 

Chloral hydrate and bromide of potassium, equal parts, ten to 
fifteen grains of each, may be injected into the rectum ; it may be dis- 
solved in about half a teacupful of warm sweet milk or warm starch- 
water. After the chloral and bromide have been thus injected, it is 
usually necessary to press upward with a folded cloth against the 
rectum for five or even ten minutes, to prevent the medicine from 
being ejected. In some instances from twenty to thirty grains of 
chloral may be given in a solution alone per rectum, as above described. 
If this does not afford relief, extract of belladonna, one-half grain, may 
be given in a suppository by the rectum, to relieve severe pain. Con- 
stipation may occasionally be overcome with small doses of calomel 
and soda. Wythe's triturates, one-tenth of a grain night and morning, 
or one-twentieth of a grain, may be sufficient to overcome constipation. 
In severe cases of constipation a good plan is to take one-tenth of a 
grain every two hours until the bowels move; then follow this with a 
dose of Rochelle salts. The small doses of calomel and soda may be 
repeated occasionally if the tongue becomes brown-coated at the base 
or back part. The food should be such as the patient can easily digest. 
Too concentrated urine, -or the passing of too little urine, calls for a 
more liberal amount of water. As a rule, patients suffering with too 
concentrated urine do not drink enough water. Mild diuretics, as 
buchu, are very useful in all alkalinity and acidity of the urine. If 
the urine is acid, the alkaline waters are needful, such as Yichy or 
Apollinaris ; lemonade is also useful in acidity of the urine, as it 
becomes alkaline with the action of the gastric juices. It is also bene- 
ficial in inflammatory rheumatism. The lemonade may be combined 
with two or three grains of bicarbonate of soda and drunk while effer- 
vescing. 

Alkalinity of the urine is corrected by the use of the benzoates. 
Ammonium benzoas, five grains every four or ^ve hours, administered 
in an infusion of buchu, two or three tablespoonfuls to one or two 
ounces with a wineglass of water, will soon correct the alkalinity of 
the urine. Patients who suffer with irritability of the bladder from 
excessive alkalinity of the urine can have test paper (red litmus paper), 



190 Diseases of the Bladder. 

and test the morning urine themselves ; if it turns the red litmus paper 
blue, they will know why they have an irritable bladder, and can 
resort to the use of the benzoate of ammonia and infusion of buchu ; 
when the urine is no longer irritable, they can rest from its use. The 
writer has found that currant juice or jelly, one tablespoonful taken 
in a half tumbler of water every three or four hours, will soon correct 
the alkalinity of the urine. In all such cases a physician should be 
consulted. 

Some writers, — Jewet and others, — recommend, in cases of unuri- 
sis, belladonna pushed nearly to the point of intolerance, keeping in 
mind the antidote for belladonna, which is morphine. 

The galvanic current of electricity, to the strength of five to twenty 
milliamperes, the anode-active placed over the urethra, the cathode 
placed over the hypogastric region or in the vagina, according to the 
cause of the irritation of the bladder, will give very satisfactory results. 
The sittings may be given once or twice daily, each seance from ten, 
fifteen, to twenty minutes. After each seance a hot vaginal douche 
should be given, which seems to ^enhance the value of the galvanic cur- 
rent. May use twenty per cent solution of cocaine on absorbent cotton ; 
place over the mouth of the urethra while giving the galvanic current. 

CYSTITIS INFLAMMATION OF THE BLADDER. 

Cystitis in women is of frequent occurrence. The case may be 
acute or chronic, local or general. It varies greatly in intensity and 
duration, lasting from a few days to several weeks. In the beginning 
of the trouble there is congestion and swelling of the mucous membrane 
affected. In fully-developed cystitis there is more or less inflamma- 
tory thickening of the bladder wall, and the mucous surface is covered 
with muco-pus, and frequently eroded in patches. Slight hemorrhage 
may occur from the denuded areas. 

Etiology. — The causes of inflammation of the bladder are both 
local and general, although such distinction is not always absolute. 

The most important in general are the infectious diseases, espe- 
cially typhoid fever, acute articular rheumatism, pyemia and septicae- 
mia, erysipelas, influenza, mumps, scarlet fever, and smallpox, in which 
slight degrees of cystitis are frequent. In these diseases also the 
milder varieties of the acute nephritis are common, and the inflamma- 
tion of the bladder, like the nephritis or inflammation of the kidneys, 
is said "probably to be the result of the local action of the bacteria or 
toxins demonstrably or presumably concerned in the origin and prog- 
ress of these diseases." The frequent association of cystitis and gout 
is most satisfactorily explained as the result of a direct irritation by 
the concentrated urine of the mucous membrane of the bladder. The 
local causes are injuries to the bladder, which may result from the use 
of unclean instruments, or irritating urethral injections, or from the 
presence of faeces in the rectum, of pessaries in the vagina, or the foetal 



Diseases of the Bladder. 191 

head of childbirth. Also important local causes are foreign bodies, 
calculi, and invading bacteria, especially the gonococcus ; certain 
medicinal agents, as cantharides, copaiba, cubebs, and mustard, when 
absorbed and eliminated by the kidneys, may produce a cystitis. 
Retention of the urine from any cause, whether induced by strictures, 
prostatic enlargement in the male, vesical tumors, or by defective mus- 
cular contraction, as in paraplegia, is capable of exciting cystitis. 
Inflammation of the bladder may also be caused by the extension of 
inflammation from neighboring parts, as the urethra, rectum, uterus, 
vagina, or peritoneum, as is illustrated in the use of an unclean 
catheter. 

Morbid Anatomy. — "The anatomical changes [quoted from Wood] 
to be found are either characteristic of a catarrhal inflammation or are 
indicative of a pseudo-membranous or a phlegmonous process. In 
acute catarrhal cystitis the mucous membrane is reddened and swollen, 
and the contents of the bladder are either slimy or purulent, in accord- 
ance with which difference a cystitis is regarded as catarrhal or sup- 
purative. In chronic cystitis the mucous membrane is of a bluish- 
slate color in spots, and the contents of the bladder are more slimy 
than purulent. The pseudo-membranous cystitis is characterized 
either by the presence of fibrinous or, more frequently, by ecchymoses 
ulceration and superficial necroses of the mucous membrane, diph- 
theritic cystitis. These necroses appear as opaque, gray, or yellow 
patches, especially at the neck of the bladder and upon projecting folds 
of mucous membrane, and may contain urinary salts. In phlegmonous 
cystitis the submucous tissue is destroyed, and the mucous membrane 
may be detached in shreds or flakes, or even be exfoliated as a cast of 
the interior of the bladder. 

Symptoms. — The earliest as well as the most distressing and per- 
sistent symptom of inflammation of the bladder is pain. This may be 
preceded by a chill and fever, and the latter may last for some time dur- 
ing the progress of the acute inflammation. The pain is usually 
referred to the region of symphysis, but may extend to the perineum 
and to the rectum, and is somewhat relieved by micturition. More 
severe and distressing is the frequently-associated vesical tenesmus ; 
when intense it is called stranguary, compelling frequent micturition, 
perhaps every few minutes, at the end of which a few drops of blood 
may escape. The urine is opaque, high colored, and acid or alkaline. 
At the outset it may be free from albumen, although, later, albumen 
occurs, in consequence of the presence of pus or blood. "A grayish 
sediment, the so-called mucous slime, is formed, in which are particles 
of slime, giving the reaction of mucin, and numerous polynuclear leu- 
cocytes, cells of vesical epithelium, occasional red blood-corpuscles, and 
often abundant bacteria." In the milder varieties of acute cystitis the 
fever subsides in the course of a few days, vesical pain and tenesmus 
gradually disappear, and the urine becomes normal. In chronic 
catarrhal cystitis the vesical pain and tenesmus may be comparatively 



192 Diseases of the Bladder. 

slight. The opacity of the urine becomes greater and the sediment 
more abundant, containing a larger number of pus corpuscles, and a 
correspondingly increased amount of albumen. The urine is usually 
alkaline, and the pus is often transformed into a gelatinous mass, which 
adheres to the vessel in which it is contained. Digestive disturbances, 
with slight loss of flesh and strength, often result from chronic catar- 
rhal cystitis. 

The severer forms of acute cystitis may be such from the outset, 
or may be due to an acute exacerbation in chronic cystitis, and usually 
represent the result of a diphtheritic or gangrenous inflammation of 
the mucous membrane or the extension of the inflammation to the sub- 
peritoneal and paracystic fibrous tissue. The febrile disturbance is 
greater, the course is irregular, and the range of temperature is higher, 
with frequent wide daily variations between extremes. The patient 
may be delirious, somnolent, or in a condition of stupor. The forma- 
tion of an abscess is indicated by localized induration, pain, and tender- 
ness, often apparent on rectal examination. The abscess may be evac- 
uated into the bladder* with relief to the pain and discomfort, or it 
may extend toward the peritoneum, with a production of peritonitis. 
Sloughs of the mucous membrane may plug the urethra, so that in the 
female they may be withdrawn by forceps. With the continuance of 
the severe symptoms the patient may collapse, the temperature being 
sub-normal and the pulse inappreciable. 

Diagnosis. — Vesical pain and tenesmus suggest inflammation of 
the bladder, and the diagnosis is confirmed by examination of the urine. 

Prognosis. — The longer the continuance of the cystitis, the more 
doubtful is the prognosis. Recovery readily takes place in the milder 
varieties of acute catarrhal cystitis, whereas the prognosis becomes 
greater if the cystitis extends toward the kidneys or to the neighboring 
fibrous tissues. The prognosis in chronic cystitis is always serious, 
from the frequent impossibility of removing the cause, and from the 
liability to acute exacerbations. 

Treatment. — Especially important is the prophylaxis of the ves- 
ical inflammation. Among the most fertile sources of cystitis are over- 
distension of the bladder after labor, and the consequent use of the 
catheter, which should be avoided if possible. When the patient is 
unable to pass water in a reclining position, the attempt usually suc- 
ceeds if she is allowed to assume a half-sitting posture. In all ordi- 
nary cases this liberty is justifiable as early as six or eight hours after 
labor, and it exposes the patient to less danger than does the passing 
of the catheter. When the catheter must be used, the whole procedure 
should be managed with scrupulous care, to make it antiseptic ; and also 
the meatus, urethra, and its immediate surroundings, are to be cleansed 
and washed with an antiseptic, — carbolic acid in sterilized or boiled 
water, cooled down to the right temperature, — and the instrument 
passed under direct inspection of the parts. It is equally important 
for the nurse to have her own hands antiseptic before using the 



Diseases of the Bladder. 193 

catheter. The instrument should be warm and anointed with sterilized 
vaseline before passing it through the urethra into the bladder. If 
this care is especially observed, infection of the bladder will not occur. 
Before resorting to the use of the catheter to void the bladder, success 
in passing the urine is often followed by the use of a hot stream of anti- 
septic water passed over the meatus urethra, while the patient is on 
the bed-pan; it should be passed gently and slowly; the rubber tube 
may be bent a little so as to gauge the flow of water while it is passing 
over the urethral vicinity. The patient can let the urine flow. Care 
should be taken not to wet the bed. This method adds comfort to the 
patient, and it should be preferred to the first. 

In the treatment of cystitis, rest in bed, with the hips elevated 
slightly, and a warm pillow placed under the knees, is the first essen- 
tial, until the acute symptoms have subsided. The patient should be 
given a non-stimulating diet, consisting largely of fresh milk, eggs, 
and light broths. Harlock's malted milk is also very useful in cystitis. 
Stimulants and stimulating condiments, as pepper, ginger, etc., should 
be avoided. The free use of saline laxatives, as Rochelle salts and 
sulphate of magnesia, relieves vesical irritation. The skin should be 
kept active by warm bathing, hot vaginal douches, and warm, suitable 
clothing. It is especially important that the extremities be warmly 
clad. If the urine be acid, it should be rendered neutral and non- 
irritating by the free use of alkaline drinks ; citrate of potassium, ten 
to fifteen grains, three to six times a day, in a large wineglass of water, 
or flaxseed tea is very beneficial. Alkaline urine calls for benzoate of 
ammonium, given in doses of ten grains, in flaxseed tea or warm milk, 
every two or three hours, until the urine is rendered slightly acid. 
Citric-acid lemonade is said to have a like effect. Salol is particularly 
useful in alkalinity or in ammoniacal decomposition. The dose is 
from five to ten grains every two or three hours. After the patient 
has recovered from the attack of cystitis, it is a good plan to take one 
or two doses of salol daily for a month or two, as it acts as a disinfectant. 
Boric acid, given by the rectum, in doses of ten to twenty grains, at bed- 
time, in flaxseed tea, is a useful corrective when the urine is very 
offensive. The injection of liberal quantities of pure water acts to 
dilute the urine and render it less irritating. Hot flannel over the 
hypogastric region, and a hot-water bag placed over the compress, 
give great relief. Hot sitz-baths are useful. A suppository of extract 
of belladonna, quarter of a grain, and one grain of opium, given by 
the rectum every six hours until the pain is relieved, may have to be 
resorted to. Hyosciami or chloral hydrate is often successfully used. 
Ten grains of chloral in a half teacup of warm milk is the best method 
of administering it. It is best given by the rectum, in which case the 
dose should be doubled. Chloral is considered the least objectionable 
of any of the narcotics. In cases of insomnia chloral may be given 
by the rectum, and it acts in a most satisfactory manner. The action 
of bromide of sodium, in twenty-grain doses, in lemonade, given by the 



194 Diseases of the Bladder. 

stomach, and repeated once in four or six hours, is often salutary, more 
so than opium for the relief of pain and tenesmus or straining, espe- 
cially in highly nervous women. Cannabis indica in many cases sub- 
dues the pain equally as well as opium, and it has not the constipating 
effect. Rarely hypodermic injection of morphine is necessary. Fluid 
extract uva ursi, teaspoonful every three hours, fluid extract buchu, 
teaspoonful every three hours, or sodium salicylate is often given, from 
forty to fifty grains in twenty-four hours. 

Woods recommends in subacute or chronic cystitis the stimulating 
diuretics, oil of cubebs, oil of copaiba, oil of sandalwood, terebene, and 
oil of turpentine. These stimulating diuretics in acute cases of inflam- 
mation of the bladder are harmful. 

Before beginning catheterization, salol should be given so as par- 
tially to disinfect the urine. A rubber catheter is preferable, and 
should be kept in a bichloride solution, and washed in hot water after 
using. As the catheter is passed through the urethra, a solution of 
bichloride, 1 to 4000, should be sent through it, so as to disinfect the 
urethra. The bladder should then be washed out with a strong solution 
of table salt, — a large tablespoonful to a quart of sterilized water, — 
and this should be followed afterward by a salt solution one-fourth as 
strong. After a time, when catheterization is daily practised, the tissue 
becomes so hardened and difficult of infection that absolute asepsis as to 
the catheter is all that is required. 

In acute cystitis, if relief is not obtained in from twenty-four to 
forty-eight hours, the bladder should be washed out. Some writers 
recommend simple sterilized water. The writer uses boric acid, ten 
grains to the ounce of sterilized water. The patient is allowed to pass 
the solution in from five to ten minutes after the injection into the 
bladder. Two to four ounces is the usual amount of the boric solu- 
tion injected, then sterilized water for rinsing out the bladder is used. 
This treatment is repeated twice a day. Silver nitrate in one-half to 
two per cent solution is recommended, and is, according to the opinion 
of various surgeons, the most generally efficacious of all the local appli- 
cations. In many cases it produces great pain, and it should, therefore, 
be first used in small quantities and in the weakest solution ; one-half of 
one per cent to one and two per cent solution should be persistently 
used. In washing the bladder, it is better to never fully distend the 
bladder. When the soft, warm rubber catheter has reached the bulbo- 
membranous portion of the urethra, sterilized water should be sent 
through it by means of a fountain syringe, and allowed to flow back, so 
as to wash out the urethra. The catheter should then be passed into the 
bladder, and from one to two ounces of the solution injected and after- 
wards withdrawn. About the same quantity should be injected several 
times, until the viscus is thoroughly cleansed. To prevent absorption, 
the final washing should be simple sterilized water. There are reported 
cases of poisoning from the use of boric acid. In most cases the solu- 



Diseases of the Bladder. 195 

tion for washing the bladder may be alternated with other solutions, as 
salicylate of sodium. Dr. Jewet recommends methylene blue, gr. i to 
gr. ij, water, oz. j ; hydrogen-dioxide, diluted with one to three meas- 
ures of boiled water, as useful injections in purulent cases. Injec- 
tions of ichthyol in water (one-half to one per cent) have been highly 
recommended. Ichthyol is especially useful in gonorrheal cystitis. 

In cases of much pain after the use of a stimulating injection, the 
bladder may be washed out with a solution of hydrochlorate of cocaine, 
using a few drops of a two to four per cent solution. Care must be 
taken that a toxic dose of cocaine is not left in the bladder. 

Some writers recommend that, for the relief of pain after wash- 
ing the bladder with any irritant, morphine, one to two grains to the 
ounce of sterilized water, be injected and retained about five to ten 
minutes, and then ejected. 

When there are erosions in the bladder and along the urethral 
canal, toxic medicines are no doubt more or less absorbed, hence great 
care should be taken in these cases. 

When other measures fail, the bladder must be drained, as rec- 
ommended by the writer upon this subject, which comes under the 
domain of surgery. 

Many women who have chronic cystitis, and who need to have the 
bladder washed out daily, can be taught to do this by their attending 
physician. A small fountain syringe and a rubber catheter, and a 
short glass tube for connecting the catheter to the rubber tubing, is all 
that is needed. The syringe should be put into boiling water a few 
minutes before using it, and a stream of boiling water with a little 
boracic acid in the water, should be passed through the syringe, after 
the catheter is attached to it ; this stream of boiling water sterilizes the 
tube and catheter. Let the solution of boracic acid — ten grains to the 
ounce of water, two to four ounces, is the amount generally prescribed 
by the writer — cool down to a little more than blood heat. This 
should be prepared ready to put into the syringe immediately after the 
boiling water has been passed through the syringe, which keeps warm 
until the solution is all injected. Just before passing the catheter 
into the bladder, let the solution pass down into the catheter until a 
few drops flow out, quickly pinch the rubber tube tightly, and, having 
the catheter previously anointed with sterilized vaseline, it may now be 
passed gently and gradually into the bladder ; let the solution flow in 
until all has passed out of the fountain, and not quite all passed out of 
the tube; pinch it again gently and quickly, withdraw the catheter 
slowly, while the tube is being pinched or bent, so as not to admit of 
any air passing into the bladder. The writer teaches some chronic 
patients this procedure, and they wash out the bladder daily, and so 
far she has never had a patient who has performed this part of the treat- 
ment of the bladder according to instructions, that has not improved 
under her own care. Oftentimes patients are not financially able to 



196 Diseases of the Bladder. 

go to a physician daily for this treatment, and when a woman is intel- 
ligent, and has some confidence in her own ability, she will easily be 
instructed. It is a good plan to have the patient take an antiseptic 
wash before she washes out the bladder, so as to disinfect the vicinity 
of the urethra, and also her hands should be washed with hot water and 
soap before using the catheter, especially her finger nails should be 
antiseptically treated before the commencement of the irrigation of the 
bladder. 

TUBERCULOSIS. 

Tuberculosis is regarded as a very rare disease. It is said, how- 
ever, that cystitis may yet prove to be more frequently of tuberculous 
origin than has hitherto been assumed. 

Pathology. — The favorite seat of vesical tuberculosis is the neck 
of the bladder. In the early stages of the disease, the mucosa is 
described as being studded with miliary tubercles. These coalesce 
into caseous nodules, and later jtlie tuberculous patches break down into 
ulcers. 

Symptoms. — Are those of cystitis. 

Diagnosis. — Absence of the usual causes of cystitis are significant. 
Tubercular disease of the bladder is at once suggested by the presence 
of tuberculosis in other organs. Direct examination through the open 
speculum is the most conclusive. 

Prognosis. — The prognosis is bad. In exceptional cases the 
patient may live for many years. Generally in two or three years 
death results from general tuberculosis. 

Treatment. — The systemic treatment does not differ from that 
adopted in tubercular diseases in other organs. Local injection of 
glycerine-iodoform mixture has been found useful. Pain is to be con- 
trolled as in other forms of cystitis. The tuberculous patches can be 
satisfactorily treated by electrolysis. Wash the neck of the bladder 
and the meatus and the surrounding parts with peroxide of hydrogen, 
then with sterilized water; then put on iodoform ointment after the 
electrical seance. It is best done with a platinum needle. Some- 
times one treatment of galvanism is sufficient. The peroxide is used 
daily, a teaspoonful in a half to a teacupful of sterilized m water for 
cleansing. Dress with iodoform ointment, two drams to one of 
vaseline. 

INVERSION OF THE BLADDER. 

Inversion of the bladder through the urethra is very seldom met 
with. It consists generally, as is said, in a prolapse of all the coats, 
not of the mucous membrane alone. It may occur at any age, but is 
most frequently observed in children. It is sometimes brought on 
abruptly by violent straining efforts during defecation or micturition. 

Symptoms. — In partial prolapse of the vesical wall before the 
tumor makes its appearance at the meatus, the symptoms do not differ 



Diseases of the Bladder. 197 

essentially from those of a foreign body in the bladder. In adults 
there is abdominal pain and vesical tenesmus when the prolapse is com- 
plete. In children these symptoms are seldom noted. The tumor is 
said to reach the size of an orange, but is usually easily reducible. In 
chronic cases the vulva and thighs are eroded from the constant 
dribbling of the urine. Continued contraction upon the ureter some- 
times results in urethritis. Extension of the inn animation may reach 
the kidneys, and uraemia may then result. 

Diagnosis. — When reduction is possible, differentiation is easily 
made between vesical polypi and inversion by exploring the cavity of 
the bladder, after replacing the tumorous or protruding mass. 

Urethral polypi can not be reduced within the bladder. The 
tumor in the urethral prolapse springs from the margin of the meatus, 
while in vesical prolapse it is encircled by it. In the former, as pro- 
truding mass, the urethral opening appears in the center of the tumor ; 
in the latter, it is annular, and surrounds the neck of the tumor. 

Treatment. — The vesical protrusion should be carefully cleansed, 
and, if possible, replaced. First elevate the hips considerably for 
gravitation ; oil the tumor with sterilized olive oil, and use gentle taxis. 
The use of a large sound helps to secure complete reduction, but it 
should be very carefully used, or omitted altogether if possible, owing 
to the danger of mechanical injury to the bladder. In partial inver- 
sion, slight forcible distention of the organ by the means of a suitable 
injection may assist in repositing the prolapsed portion. In difficult 
cases the manipulation should be undertaken with the aid of an anes- 
thesia. After the reduction of the prolapse, the patient must rest in 
bed for several days. A compress of surgeon's lint or sterilized gauze 
and a "T" binder may be used for retention. Straining at stools must 
be prevented by the use of laxatives or rectal injections, and vesical 
tenesmus controlled by suppositories of opium or hyoscyamus, or other 
suitable measures. 

VESICOVAGINAL FISTULA. 

Vesico-vaginal fistula is a direct communication between the blad- 
der and the vagina. The size of the opening may be no larger than a 
pin-point, or the whole vesico-vaginal septum may be destroyed. The 
opening may be round, angular, or a mere slit. Usually there is but 
one orifice. Occasionally there may be several. The tissues about the 
fistula may vary greatly in thickness, density, unevenness of the sur- 
face, and color. Dr. Malcolm McLean describes a case in which half 
the bladder was found prolapsed through a large vesico-vaginal fistula, 
and protruding at the vulva. The fistulous opening extended from the 
cervical junction to within three-eighths of an inch of the pubic arch. 
The width of the fistula, transversely, was two and one-fourth inches. 
The urethra was also destroyed. 

Etiology. — Vesico-vaginal fissure occurs most frequently from dif- 



198 Diseases of the Bladder. 

ficult labors during childbirth, in which the head of the child is arrested 
in the lower portion of the birth-canal. Necrosis takes place from 
long-continued compression of the vesico-vaginal wall between the head 
and the pubic bones, and the injured structures subsequently slough 
off, leaving a fistulous opening. Lacerations occurring during for- 
ceps or other instrumental deliveries seldom invade the bladder. Very 
rarely calculi or other foreign bodies in the bladder may perforate the 
vesico-vaginal septum. 

Symptoms. — The most prominent symptom is the discharge of the 
urine through the vagina. In case of a large fistula the flow will be 
constant. If the opening is small, the escape may be temporarily pre- 
vented by the pressure of the anterior vesical wall against the orifice. 
Sometimes a portion of the urine may be voided through the natural 
channel. The vaginal canal frequently becomes coated with urinary 
salts. In all cases the vulva and the inner surface of the thighs are 
excoriated by irritation from the discharge, and the odor of the decom- 
posing urine is given off from the person and the clothing of the patient. 

Diagnosis. — Large fistulse can be diagnosed by the vaginal touch; 
small ones by ocular inspection, with the aid of a small probe or sound. 
By injecting into the bladder milk and water, or methyl-blue, one grain 
to the ounce, the existence and the location of a fistula can be most 
readily demonstrated. Pozi suggests that the anterior wall of the 
vagina be dried carefully and covered with a piece of absorbent paper ; 
a moist spot on the paper locates the seat of the fistula. When once 
located the direction and the extent of the fistulous tract may be deter- 
mined by the probe. Sometimes the examination is rendered difficult 
by cicatricial contraction of the vagina. Preliminary dilatation may 
then be necessary to expose to view the seat of the fistulous opening. 

Treatment. — For vesico-vaginal fistula, the treatment is: first, 
preparatory, building up the general constitution for a time, tonics, 
and hygienic treatment for the improvement of the general health. 
Time must be allowed after labor for a completion of the process of 
involution and for full convalescence. This usually requires three 
imonths at least, or even more. 

The diseased structures about the fistula should be placed in the 
best possible condition for repair. The vaginal canal should be kept 
*clean from urinary deposits, with hot boric-acid douches, two drams 
*o the quart of water, repeated two or three times a day, for some weeks 
previous to the closing of the fistula, or operating. Erosions of the 
vagina may be touched with nitrate of silver (ten grains to the ounce 
of water) three times a week if necessary, for the same length of time; 
for closing of the vesico-vaginal fistula calls for an operation, which 
should be performed by a gynaecologist of some experience in this branch 
of medical work. 



Diseases of the Bladder. 199 

STONE IN THE BLADDER VESICAL CALCULI. 

Stone in the bladder is a far less common affection of the female 
than of the opposite sex. This is said to be accounted for mainly by 
the greater facility with which small stones are expelled through the 
female urethra. 

Symptoms. — The patient suffers from frequent urination, dysuria, 
tenesmus, and occasionally onuresis. The flow may be abruptly cut off 
at micturition, owing to the occlusion of the vesical neck by the stone. 
A more or less severe cystitis always coexists. Hematuria may occur 
if the shape of the calculus be such as to cause abrasions. The urine 
contains pus, epithelium, and mucous, with amorphous crystals of 
triple phosphates. 

Diagnosis. — "The diagnosis is made with the sound, by a cysto- 
scopy examination, by digital exploration through the urethra previ- 
ously dilated, or by conjoined abdominal and vaginal palpation. As 
rigid an asepsis should be observed in the use of the exploring finger 
and sound as is practised in major operative procedures. 

"The bladder should be evacuated and thoroughly irrigated with a 
normal salt solution, or, better, with a two-per-cent boric acid solution. 

"When a sound is to be used, the bladder should be moderately 
distended with a two-per-cent boric acid solution, or a normal salt 
solution. The movements of the sound are thus unobstructed, and 
vesical folds which might envelop the stone are obliterated. The search 
is to be systematically conducted, first over the most dependent por- 
tion of the cavity, then over the rest of the bladder walls, one or two 
fingers of the disengaged hand guiding and assisting the manipulations 
through the vagina. 

"Cystoscopy, or digital exploration, may serve to discover an 
encysted stone which has escaped detection by the sound. Dilatation 
of the urethra, sufficient to admit an index finger of not more than 
average size, is rarely followed by persistent incontinence. The digital 
exploration is to be assisted with the fingers of the other hand, through 
the vagina. 

"Prognosis. — The prognosis is good in the absence of renal and 
severe vesical lesions. 

"Treatment. — Calculi may be removed by the way of the urethra, 
or by vaginal or supra-pubic cystotomy. Small calculi can be extracted 
through the urethra, after dilatation with graduated dilators, or 
removed with slender forceps through a Kelly speculum. Moderately 
large stones, if friable, may be crushed by the usual method, or under 
direct inspection with the aid of the open speculum, the debris 
washed out. If there is much cystitis, and the stone be of large size, 
and too hard to be crushed, vaginal or supra-pubic cystotomy is to be 
preferred ; for not only may the stone be thus removed with less result- 
ing injury to the bladder, but drainage for the diseased organs is 
secured. This method of treatment is surgical." 



200 Diseases of the Bladder. 

FOREIGN BODIES IN THE BLADDER. 

Foreign bodies may be introduced into the bladder through the 
urethra, either by accident or by intention. Lead pencils, pipe stems, 
ligatures, hairpins, crochet needle, rubber womb protector, are among 
the articles reported to have been found in the bladder. Stumpff is 
said to have related a case of hematuria due to the presence in the 
bladder of a pigeon's feather, covered with ointment. 

Symptoms. — The symptoms are reported to be substantially the 
same as in stone. 

Diagnosis and Treatment. — The same as for stone in the bladder. 

VESICAL TUMORS. 

Tumors or neoplasms of the female bladder are of infrequent 
occurrence. They include papiloma, myxoma, fibroma, myoma, sar- 
coma, epithelioma, and carckioma. The malignant forms are more 
frequently met with than the benign. "Most commonly their site is 
the base of the bladder." 

Symptoms. — The most common symptom of vesical neoplasm is 
hematuria. Growths at the neck of the bladder give rise to frequent 
and painful urination. By falling over the urethral orifice, they may 
interrupt the flow of urine at micturition, or may cause retention. 
Clots from free hemorrhage may obstruct the vesical orifice. Tenes- 
mus is usually extreme. Cystitis may be looked for sooner or later. 
Urethritis and pyelonephritis commonly supervene. Fragments of the 
tumor are occasionally expelled through the urethra. Tenesmus aggra- 
vates the morbid condition of the mucous membrane. With the grow- 
ing neoplasm the hemorrhage increases. The urine contains pus, 
blood, mucus, epithelial scales, neoplastic shreds, and phosphates. The 
general health is in time impaired, the patient becoming thin, anaemic, 
and cachectic. 

Diagnosis. — Diagnosis is made by conjoined abdominal and 
vaginal manipulation, by the electric cystoscope, by direct examination 
with the finger through the urethra, or by ocular inspection through 
the open speculum. 

Treatment. — Very small growths, which are pedunculated, may 
be twisted off and removed through the urethra. "Troublesome 
hemorrhage is to be controlled by irrigation with warm water, or by 
gauze packing, with counter-pressure over the abdomen. The large 
tumors are removed through the urethra, by a vesico-vaginal incision, 
or by epicystotomy. For a few days after the operation the bladder 
should be washed out daily with a two-per-cent solution of boric acid ; 
the urine, in the meantime, is to be kept bland by alkaline drinks." 

The Burne and Skene method consists in employing the cautery 
in the treatment of vesical neoplasm. Skene makes a vesico-vaginal 
fistula, brings the growth, or sections of it, into the opening, and when 



Diseases of the Bladder. 201 

possible through the vagina, clamps the base, most of which should be 
normal mucous membrane, with forceps, cuts it off with the galvano- 
cautery, and desiccates the portion within the grasp of the forceps. The 
bladder is carefully washed out with a half-strength Thiersch's solu- 
tion and closed. For twenty-four hours after the operation the 
catheter is passed every two hours, then every four hours. 

THE URETERS. 

Anatomy. — The ureters are the membranous tubes which conduct 
the urine from each renal pelvis of the kidney to the urinary bladder 
within the pelvis. They are generally about fourteen and a half 
inches in length, and from one-eighth to one-sixth of an inch in 
diameter (according to McClellan). They are behind the peritoneum, 
and appear as pale collapsed tubes, descending in the psoas muscle, 
and passing over the bifurcation of the common iliac arteries. In the 
female the ureters penetrate the plexus of uterine veins beneath the 
broad ligament. The walls of the ureters consist of three coats. There 
are many lymphatic vessels, and a few arteries derived from the renal, 
lumbar, and common iliac arteries. The nerves come from the renal 
and hypogastric plexuses. 

DISEASES AND INJURIES OF THE URETERS. 

Stone in the Ureters. — A calculus is liable to pass from the kidney 
through the canal, and do but slight injury to its mucous membrane, 
or it may cause deep abrasions, or become lodged in the tube. It is 
said when a stone is arrested in its descent, it lodges most commonly 
about two inches below the kidney, at the constriction of Bruce Clark, 
or at the bladder orifice of the ureter. Uretritis follows, and if the 
obstruction is not relieved, hydronephrosis and destruction of the kidney 
results. 

Symptoms. — When a stone enters the ureters, renal colic ensues. 
The pain sets in abruptly without apparent cause, or it may be initiated 
by sudden muscular efforts. It is characterized by agonizing pain, 
which starts in the flanks of the affected side and passes down the 
ureter. Vomiting occurs during the painful paroxysms. Micturition 
is frequent, occasionally painful, and the urine is sometimes bloody. 
There is tenderness on the affected side. In very thin persons the 
stone may possibly be felt on abdominal palpation along the course of 
the ureters. When the stone is arrested in the pelvic portion, it may 
be located by palpation through the rectum. 

Treatment. — "When the obstruction is complete, as is shown by 
negative catheterization of the ureter, an operation is indicated.'' 

Ureteritis. — Ureteritis sometimes occurs from extension of the 
inflammatory process from the bladder, from the kidney, or from the 
surrounding structures, or may arise from causes which reside in the 



202 Diseases of the Bladder. 

ureter itself. The disease may be septic from gonorrhoea, or tuber- 
cular in character, and may affect one or both ureters. Peri-ureteritis 
may result by the inflammation spreading to the surrounding connective 
tissues. 

Symptoms. — An almost constant symptom of ureteritis is fre- 
quent desire to micturate. There is sharp, burning pain over the ureter, 
most usually on the left side. Pain is increased during menstruation, 
and is sometimes so intense that the patient is confined to her bed. The 
urine is frequently scanty, and is of a highly acid reaction in the 
absence of cystitis, and it is said to contain pus and blood. The pres- 
ence of pus without excess of mucus is almost diagnostic of ureteritis. 
On palpation through the vagina the ureters are found thickened, 
tender, and sometimes sacculated. The patient complains of severe 
pain and desire to urinate when the inflamed ureter is pressed under 
the finger. 

" Skene states the history in cases following obstetrics. The 
symptoms are those of pelvic pain and tenderness in the lower abdomen, 
which at first may not be severe. Usually the symptoms become more 
acute after a time, the pain and tenderness increasing rather abruptly. 
A chill or rigor may occur, with some tympanitic distension of the 
bowels, and the temperature may rise to 102 degrees or even 105 
degrees Fahrenheit, with corresponding acceleration of the pulse. 
The tenderness is markedly increased on pressure, and manual manip- 
ulation of the affected part causes distress rather than acute pain. 
These symptoms increase in severity in from three to iive days, and 
soon thereafter pus and blood may be found in the urine. With 
the appearance of purulent urine the patient's condition generally 
improves; pain and tenderness are to some extent relieved, the pulse 
becomes less rapid, and the temperature falls. The bleeding subsides 
in a few days, but the pus discharge continues for a week or more. In 
other cases the inflammation pursues a different course, and about the 
time that pus appears in the urine and is discharged into the bladder, 
acute disease of the kidney supervenes, with diminution of the urinary 
secretion and varying degrees of ursemic intoxication." 

Treatment. — The coexistent cystitis should first be treated in 
the usual manner. Rest in the recumbent posture must be insisted 
upon, the bowels freely open with salines, — Rochelle salts, Epsom 
salts, sulphate of magnesia, citrate of magnesia are the saline mixtures 
usually used in these cases, — morbid urinary conditions corrected, and 
the urine rendered antiseptic with salol. In vesical irritation if the 
urine is acid, hot lemonade will soon give relief. It should be taken 
every hour or two. It will aid in rendering the urine less acid. If 
the urine is alkaline, pure unadulterated currant jelly, one tablespoon- 
ful stirred into a large tumblerful of boiling water, is very palatable. 
It may be taken every three hours. The juice of navel oranges and 
grape-fruit are valuable aids in correcting the alkalinity of the urine. 



Diseases of the Bladder. 203 

The diet should be restricted, largely milk, if it does not cause flatu- 
lence; many women can not digest milk comfortably, in which case 
Harlock's malted milk may be tried, as it usually agrees with most 
patients. A pint of boiled water may be drank an hour before regular 
meals. Vichy's mineral water acts favorably by flushing the urinary 
tract. 

" Skene advises high rectal enemata of warm water ; given in quan- 
tities from one pint to one quart, it will be absorbed, and have a 
diuretic effect. If there is constriction of the urethral orifices suffi- 
cient to cause hydro-ureter, catheterization followed by dilatation with 
bougies, is indicated." 

"Bozeman makes a large opening in the base of the bladder in the 
region of the ureter, and brings it under direct observation. He then 
passes a catheter, and through it irrigates the ureter and pelvis of the 
kidney with a bland antiseptic solution." 

Operative and Other Injuries. — The ureter is liable to injury in 
abdominal operation upon the pelvia viscera and in vaginal hysterec- 
tomy. The ureters are liable to be ligated through mistake or severed, 
as has been recorded in several instances. The treatment is to do the 
work over, and thereby correct the errors made. 

Extirpation of a normal kidney, for injury or disease of the 
ureter, is considered by some writers as utterly unjustifiable, except 
where the ureter can not be restored. 



CHAPTER XI. 

DISEASES OF THE RECTUM AND ANUS. 

11ECTUM. 

Anatomy (McClellan's). — In the adult the rectum is situated 
entirely within the true pelvis, while in the infant its upper portion is 
in the false pelvis, or lower part of the abdomen. In the infant it is 
also nearly straight, but in the adult it presents three marked curves, 
one lateral and two anteroposterior, as follows : It commences oppo- 
site the left sacro-iliac symphysis, curves slightly to the right of the 
median line, and then descends, adapting itself to the shape of the 
sacrum and coccyx, and at the tip of the coccyx it bends Backward to 
terminate in the anus. The rectum is cylindrical. It is narrowest 
at the upper part, and gradually increases in size toward the anus, 
immediately above which it presents a dilatation, the ampula analis, 
capable of being enormously extended. The rectum is about twenty 
centimeters, or eight inches, in length, and its upper portion is entirely 
invested with the meso-rectum. Anteriorly, the recto-vesical pouch of 
the peritoneum is within from seven to ten centimeters, or from two 
and a half to four inches, of the perineum. Posteriorly, the perito- 
neum does not come within nine centimeters, or three and a half inches, 
of the anus. 

The muscular coat of the rectum differs from that of the caecum 
and colon in that its longitudinal layer completely surrounds it, and 
that both the longitudinal and the circular fibers are well developed, 
resembling those of the oesophagus. 

The longitudinal fibers become lost in the connective tissue about 
the anus. They are augmented by a band of fibers which extends on 
each side from the coccygeal vertebra to the margin of the rectum, the 
recto-coccygeus muscle. 

The circular fibers become thickened about six millimeters, or 
about one-quarter of an inch, from the anal orifice, forming the internal 
or deep sphincter-ani muscle. The external sphincter-ani muscle is 
very closely associated with the skin, from which it is difficult to sepa- 
rate it, except in the most recent state. It is elliptical, consisting of 
two layers of curved fibers which arise from the ano-coccygeal liga- 
ment and the tip of the coccyx, and, surrounding the anus, are attached 
mainly by a pointed slip at the central tendon of the perineum. There 
are numerous fibers from the superficial layer, which intermingle with 
several adjacent muscles, and decussate with one another in front of 

(204) 



Diseases of the Rectum and Anus. 205 

and behind the anus. The deep layer is in relation with the internal 
sphincter-ani muscle, which is the ring of involuntary circular and 
muscular fibers surrounding the lower portions of the rectum, six milli- 
meters, or about a quarter of an inch, from the margin of the anus. 
The external sphincter is a voluntary muscle supplied by the fourth 
sacral nerve, and by its tonic action it keeps the anus closed. In the 
operation of fistula-in-ano the external sphincter is divided in order to 
keep the parts at rest during the healing process, and the incision 
should be made parallel to the course of the inferior rectal vessels. 
These vessels arise from the pudic, and cross obliquely with the anal 
nerves through the ischio-rectal fossa to the lower wall of the rectum, 
and the skin about the anus. Occasionally they are of large size, and, 
if wounded, may give rise to troublesome bleeding. The mucous 
membrane of the rectum is very vascular and thick, and so loosely 
attached to the muscular coat that in children in whom the bowels are 
straighter, as stated above, it predisposes to prolapsus. There are 
three permanent semilunar folds of the mucous membrane — Houston's 
valves. The first, situated opposite the prostate gland, projects back- 
ward; the second, opposite the middle of the sacrum, projects inward 
from the left side ; the third, near the commencement of the bowels, 
projects from the right side. The middle one is always the most prom- 
inent. When the rectum is empty the mucous membrane appears 
folded longitudinally (volumnse-recti), and at the verge of the anus is 
gathered into looped folds, called the valvulse morgagni. 

The arteries which supply the caecum and the colon are the branches 
from the right border of the superior mesenteric artery, and branches 
from the superior mesenteric artery. They are the colica media, colica 
dextra, colica sinister, colica sigmoidea, and ilio-colic arteries. The 
veins from the different portions of the colon join the inferior and 
superior mesenteric branches of the portal system. The rectum has a 
special blood supply from three diverse sources. The superior rectal, 
or superior hemorrhoidal artery, comes from the inferior mesenteric 
artery; the middle rectal, or middle hemorrhoidal artery, from the 
special blood supply from three diverse courses. The superior rectal, or 
inferior hemorrhoidal artery, from the internal pudic artery. The 
disposition of the arteries in the lower part of the rectum is very 
peculiar. They pass parallel to one another toward the anus, and 
freely communicate by large transverse branches. The veins are sim- 
ilarly arranged, and establish the hemorrhoidal venous plexus about the 
lower end of the rectum. The main trunks from the latter are the 
superior hemorrhoidal veins, tributaries of the inferior mesenteric 
vein, and the middle and inferior hemorrhoidal veins, which terminate 
in the internal iliac veins, so that the portal and general venous system 
are brought into direct communication. To this fact is chiefly attrib- 
uted the tendency of the veins about the anus to become varicosed, and 
to the formation of piles or hemorrhoids. The nerves of the rectum 



206 Diseases of the Rectum and Anus. 

are derived from the inferior mesenteric, hypogastric, and sacral 
plexus. 

The anus, or rectal orifice, is an irregular puckered opening about 
three-fourths of an inch in length, during life, when distended. The 
wrinkling of its margin is caused by contraction of a thin layer 
of involuntary muscle-fibers in the sub-cutaneous tissues, called 
the corrugator-cutis-ani muscle. Close to the verge of the anus, 
there are clusters of papilla?, and many minute glands which 
secrete an oily substance. On the border line between the skin 
and the mucous membrane, the anal veins often present varicosi- 
ties, which, when large, constitute external piles. This border line 
also presents a fine white streak which indicates the interval between 
the external and the internal sphincter-ani muscle. The anal branch 
of the pudic nerve supplies the skin of the verge of the anus; and a 
great pain often experienced in a fissure of the anus, is due to the 
exposure of the filaments of this nerve in the torn tissue. 

Physiology. — When at rest the sphincters are constantly on guard, 
and keep the orifice closed. If the patient has a lesion of the dorsal 
cord, they become relaxed, and there is incontinence of faeces. The 
act of defecation has for its origin a vague sensation of weight, due to 
the pressure exercised upon the anus by a faecal mass. This sensation 
induces a reflex contraction of the muscular tunic of the rectum, which 
tends to force toward the anus the accumulated material. If the 
sphincters offer resistance, an anti-peristaltic action results, pushing 
the faecal matter toward the upper part of the rectum. The tonicity of 
the sphincter, however, has a limit, which is overcome when the column 
formed by the faecal material is high. In such cases a single peri- 
staltic movement of the intestines is sufficient for the act of defecation, 
by which the latter is accomplished in the ordinary way. If the 
material becomes solid, it requires a severe muscular effort for relief. 

Injuries of the Rectum. — Injuries of the rectum are of two kinds, 
accidental and surgical. The causes of injuries vary, as, falling from 
a height onto a pointed body, sliding off of high places upon any sharp 
or pointed instrument or tools, as sliding off a hayrick upon the point 
of a fork or fork handle, the careless use of a sound or the tip of a 
syringe. Straining at stools may cause partial rupture of the rectum 
walls. Parturition is a well-known cause. 

Diagnosis. — The diagnosis is usually made by the symptoms, as, 
local pain, discharge of blood and muco-purulent material by the anus, 
the passage of the faecal matter through the vagina or with the urine, or 
the escape of the urine by the rectum. Hemorrhage is a symptom of 
sufficient significance to demand interference. Such injuries are 
sometimes complicated by peritonitis. If the inflammation extends 
gradually, it may be circumscribed and not be grave, unless the peri- 
toneum has been injured, and there is a communication with the blad- 
der or the rectum. Peritonitis then becomes of a very acute character, 
and the patient rapidly succumbs. Peri-rectal phlegmen may arise, 



Diseases of the Rectum and Anus. 207 

the complication of which generally terminates in the formation of a 
fistula. / 

Prognosis. — The prognosis will depend entirely upon the situa- 
tion, extent, and depth of the wound. Kecovery in the majority of 
cases is the rule. 

Treatment. — Hemorrhage at the time of the accident may be 
severe or dangerous even. The cavity should be firmly packed with 
gauze, or an important blood-vessel should be ligated or secured by tor- 
tion. Pain may be allayed with opium. Cold applications or an ice- 
bag may be applied over the affected region to check the inflammation. 

FOREIGN BODIES IN THE RECTUM. 

Foreign bodies in the rectum are caused by swallowing some for- 
eign substance, as buttons, small pieces of money, false teeth, etc., 
those which may have been introduced through the anus, and those 
which may have been formed in the rectum. 

Foreign bodies may reach the rectum through the intestinal tract. 
Montgomery reports a case of Merton's, in which a fish-bone had per- 
forated the rectal and the uterine wall, and implanted itself in the, 
foetus. 

In cases where subjects have been known to introduce foreign 
bodies through the anus, they are usually of depraved habits. Peder- 
asty and abnormal sexual impulses are said to afford the motives. The 
character of foreign bodies reported is such as beer glasses, mortar- 
pestles, marbles, and pebbles. 

In children there are frequently masses of lumbricoid worms. An 
accumulation of excrement may form a hard mass. Such masses are 
frequently found in aged women, especially in hysterical and par- 
tially demented cases. In the faecal masses may be found cherry or 
plum or peach stones imbedded in the hardened faecal matter. The 
true cause is the diminished reflex power in the large intestines, and the 
defective contractions of the muscular fiber, with the presence of a 
retained hard faecal mass which acts upon the formation of the struc- 
ture of the rectal surface. Dilatation of the rectum about a faecal 
calculus or impaction occurs, and finally an ulcerative condition or 
inflammation follows, which constitutes the characteristic lesion. 

Symptoms. — The symptoms are those which arise from the accu- 
mulation of faeces, also the pain produced by proctitis, a sensation of 
weight on the perineum, sero- sanguineous diarrhea, which is more or 
less fetid, but most important of all is constipation. Lumbar and 
crural pains are prominent, with a frequent desire to defecate, and the 
inability to perform that function. The faeces, or scybala, are often 
dry and hardened when they are expelled. Straining and efforts at 
evacuation are laborious and painful. Prolonged retention of faecal 
matter reacts bodily upon the general health, causing toxaemia, digestive 
disturbance, hepatic pain, and nervous irritability. 



208 Diseases of the Rectum and Anus. 

If the condition arises as the result of a true foreign body in the 
rectum, the symptoms are more acute and severe. After about thirty- 
six hours, the patient is forced to seek surgical intervention, and will 
complain of pretty severe pain in the belly, and a sensation of weight 
at the level of the anus. The bladder and uterus may become inflamed. 
The peritoneum also may become involved in inflammation. Pro- 
longed retention of foreign substance in the rectum may cause inflam- 
mation and even gangrene of its walls, pelvic cellulitis, hypogastric 
phlegmon, abortion, and intestinal obstruction. 

Diagnosis. — The diagnosis is sometimes difficult. When the rec- 
tum is examined by palpation, if the patient complains of obstinate 
constipation, with pain in the region of the rectum, perineum, and base 
of the bladder, with a small hand made to pass into the rectum, a 
foreign body may be found as high as the sigmoid flexure. 

Prognosis. — The prognosis is generally favorable, and will depend, 
to some extent, upon the character of the body and how it has been 
introduced. If it is fragile or sharp, and has been introduced through 
the anus, its removal may be attended with difficulty. 

Treatment. — rThe treatment is varied to suit each case. In some 
cases it requires all the surgeon's ingenuity to accomplish the successful 
removal of the foreign body. Where the body is situated high up it 
may be necessary to resort to abdominal section, and to accomplish its 
removal by incisions of the intestine and subsequent suture. In some 
cases, it is said, a posterior rectotomy may be sufficient. Foreign bodies 
of small size may be extracted from the rectum with the forceps or with 
the fingers ; if large, ether should be given, the rectum dilated, and the 
body removed. The patient should rest in bed until all inflammation 
is abated. 

Wounds of the rectum are treated by free drainage and antiseptic 
dressing. 

ASTAL PRURITIS. 

Pruritis of the anus is a symptom, and not a disease. It may be 
due to piles, fissures, seat-worms, eczema, nerve disturbances, kidney 
disease, jaundice, constipation, opium habit, torpid liver, dyspepsia, 
alcohol ,vesical calculus, smoking, urethral strictures, uterine diseases, 
ovarian trouble, or menstrual disorder. The itching, which is usually 
fearful, is the worst at night. 

Treatment. — The treatment necessarily depends upon the cause, 
which must be sought for and removed. Before going to bed wash out 
the rectum with hot water, with a little boric acid in it. Wash also the 
neighboring parts with very hot water with boric-acid solution, half a 
teaspoonful to a half pint of hot water ; then spread oxide of zinc oint- 
ment over the affected parts, and lay a thin piece of gauze between to 
keep the surfaces apart. The parts may be treated in a similar 
manner after each micturition. 

Another very effective remedy in allaying the pruritis is sul- 



Diseases of the Rectum and Anus. 209 

phurous acid diluted in hot water, made strong enough to burn a little 
when it is applied. Wash out the rectum and all the surrounding 
parts. Wash out the vagina also. When this is done, bathe the parts 
very thoroughly some four or five minutes ; then dry the surfaces and 
anoint heavily with oxide-of-zinc ointment made with pure vaseline, 
laying gauze between ; this will relieve the itching at night. 

A further remedy is nitrate of silver, ten grains to the ounce of 
water, used during the day, mopped on for a few minutes after the 
surface has been thoroughly cleansed with hot water and castile soap, 
and rinsed with hot water ; then apply the oxide-of-zinc ointment. 

Calomel and subnitrate of bismuth are very useful in ulcerated 
pruritis. Calomel, one part ; bis-sub-nit, three parts ; dust it on thickly 
after thoroughly cleansing the parts with castile soap and hot water. 

Matthews recommends: Calomel drs. ij, cosmoline oz. j; anoint 
the parts at bedtime. Campho-phenique drs, j, water oz. j ; use by 
mopping it on with a swab or camel-hair brush, night and morning. 
Seat-worms must be removed. (See article on Worms.) 

If the patient is suffering from any one of the causes above men- 
tioned, the disease must be treated in order that the pruritis may be 
permanently relieved. 

Some writers highly recommend carbolic acid one part, glycerine 
twenty parts, infusion of absinthe one hundred and twenty-five parts; 
nse two or three times a day. 

FISSURE OF THE ANUS. 

Fissure is a crack in the mucous membrane or skin at the anal 
orifice, producing spasms of the sphincter. The pain is due to exposed 
nerves, or twigs of nerves, upon the floor of the crack. Fissure is 
caused by constipation or traumatism. 

Symptoms. — The symptom is violent, burning pain, sometimes 
beginning during defecation, but usually at the end of the act, and last- 
ing for some time. Both constipation and pruritis often exist. Exam- 
ination discloses a fissure. Sometimes an operation upon the rectum 
for the removal of hemorrhoids where the rectum was not sufficiently 
dilated, will cause contraction of the sphincters, and a fissure results. 

Treatment. — Give ether, and dilate the sphincter thoroughly, 
which puts the parts to rest, and anoint them with a lotion made of lin- 
seed oil, two ounces ; spirits of turpentine, thirty drops. Twice a day 
is often enough. 

The treatment may be palliative and surgical. Wash out the 
rectum with warm water, and apply a nitrate-of -silver lotion from 
ten to twenty grains to the ounce, by wrapping a small bit of absorbent 
cotton very tightly around the end of a toothpick or a knitting-needle, 
dipped in the solution and pressed up into the base of the fissure, two 
or three times at one seance. One treatment every day usually relieves 
the patient. 

14 



210 Diseases of the Rectum and Anus. 

The surest method is to give an anaesthetic, and stretch the 
sphincter, and incise the floor of the fissure, scraping it with a curette,, 
after which dress with ichthyol ointment. If piles exist with the 
fissure, ligate them. 

PROCTITIS. 

Proctitis is an inflammation of the mucous membrane of the 
rectum. Among the causes of inflammation of the rectum are 
hemorrhoids, the abuse of drastics or purgatives, obstinate constipa- 
tion, foreign bodies, as fish-bones, biliary concretions, worms, and prac- 
tise of pederasty. Proctitis can be induced readily from gonorrhoea, 
through the specific discharge from the vagina. 

Symptoms. — The symptoms are local, being confined to the lower 
part of the digestive tube. , The patient gradually experiences a pain- 
ful sensation in the region of the sacrum coccyx, bladder, and uterus. 
The anus is red and hot, and very sensitive, and contraction of the 
sphincter occurs. Constipation is usually the rule, which may persist 
for several days. Evacuation soon becomes painful, followed by tenes- 
mus, and the expulsion of a glairy mucus and sometimes of blood. 
After the first period comes another, characterized by profuse diarrhea 
and muco-purulent discharge. In neglected or badly-treated cases, 
acute proctitis soon becomes chronic, the symptoms being somewhat 
similar in character to those already described. Diarrhea alternates 
with constipation. Examination discloses many points of ulceration, 
which are rounded and superficial, or extensive vegetations, the latter 
specially marked in cases of blenorrhagic proctitis. The thick, green- 
ish discharge attending this condition is considered a serious compli- 
cation. It produces a red appearance, excoriation, and even an 
eczematous eruption of the perineum. The mucous membrane itself 
becomes altered, thickened, sclerosed, and narrowing of the rectum may 
result. In severe cases plegmons, abscesses, or fistulae, complicating 
the intense inflammation of the rectum, are sometimes seen. The 
characteristics of proctitis are sharp pain during defecation, constipa- 
tion, and a rise of temperature, followed by a mucous discharge and 
tenesmus. In dysentery (the differential diagnosis), the frequency of 
the stools, hemorrhages, and the expulsion of shreds of mucous mem- 
brane, are the characteristic symptoms, too plain to be mistaken for 
simple proctitis. 

Treatment. — Rest in bed, enema of hot water, followed with 
astringent injections, such as one-half to one grain of sulphate of zinc 
to an ounce of warm water, to be administered night and morning. 

Nitrate of silver, one-eighth to one-fourth of a grain to the ounce 
of warm water, given night and morning; or some of the vegetable 
astringents, as tannic acid or tannin, the fluid extract of hamamelis, 
or the fluid extract of hydrastis. 

Ointments are valuable in these cases. All kinds of sedatives, 



Diseases of the Rectum and Anus. 211 

opiates, and astringents may be, in turn, tried. Allingham's formula is 
most efficacious: — 

Ijfc: Bismuth subnit 3 ij 

Hyd. sub. chlor d ij 

Morph. acet grs. ij 

Glycerine 3 ij 

Vaseline I j 

Mix. 

Syringe out the rectum with hot water, apply the ointment with 
so-called salve injector, night and morning. This is a very sedative 
application, and ulcers and sores in the rectum are speedily benefited 
by its use. 

Subacetate of lead, belladonna, and opium will be found service- 
able. A combination of extract of hyoscyamus with iodoform is often 
beneficial, especially where there is tenesmus. 

In chronic cases it is a good plan to wash out the bowels high up, — 
about twelve inches, — with hot water passed through a soft rubber 
tube which is gently passed high up into the rectum; then, after rest- 
ing the parts five or ten minutes, inject about one or two ounces of 
flaxseed tea, with about ten grains of boric acid dissolved in the tea; 
to be given at bedtime for several weeks, until all symptoms of inflam- 
mation have disappeared. 

ABSCESSES OK PHLEGMONS OF THE ANUS AND RECTUM. 

Abscesses in Ano, Ending in Fistula. — The causes are many and 
various, and several causes may combine to produce the result. These 
may be generally specified as injury to the anus, exposure to wet or 
cold, and particularly sitting upon damp seats after exercise, when the 
parts are hot and perspiring. 

Deep-seated suppuration is often found to occur after severe itch- 
ing in the part, with only redness on the surface. It may result from 
violent irritation caused by any of the forms of parasites which fre- 
quent the anus and the immediate neighborhood. Abscess, or fistula, 
may also be caused by the laceration of the mucous membrane, result- 
ing from costive motions and straining at stool. 

Fistula in children generally results from injury to the anal 
region, or from worms, which should always be asked about and care- 
fully sought for. In case of worms, medication which will remove 
them is likely to result in a cure. 

Fistula, in the majority of cases, commences by the formation of 
an abscess immediately beneath the skin, just outside of the anus, start- 
ing primarily in the cellular tissue, or in the hair or sebaceous follicles. 
It is generally said to begin in the ischio-rectal fossa?. This is a rare 
situation. It may insidiously undermine the rectum in any direction. 
Abscess and then fistula may commence by ulceration of the mucous 
membrane of the bowels, as seen in phthisical patients. When they 



212 Diseases of the Rectum and Anus. 

arise in this way, f secal matter accumulates in the parts around, and 
so a sinus is formed, which opens eventually outside of the anus. 

Abscesses may originate in the superior-pelvi-rectal spaces, and so 
form sinuses extending in any direction. 

Abscesses , or Phlegmons. — When superficial, the abscess presents 
the following appearance : There is generally a tumor the size of a hazel- 
nut, of a light red color, which, on examination, is found to be super- 
ficial, and limited by a circumscribed induration. At the end of two 
or three days, after the patient has suffered more or less pain, it 
becomes soft and fluctuating, the skin reddens and becomes thin, and 
there is a discharge of very fetid pus. The tension ceases, the pain 
disappears, and all that remains of the abscess is an induration. When 
a small abscess, however, is developed at the expense of tuberculous 
tissue, it often persists for some time as a small fistula. 

Phlegmon is situated at the margin of the anus, and is the form 
which we meet most frequently. This inflammation occurs in the sub- 
cutaneous cellular tissue, but instead of being circumscribed, it has a 
tendency to spread over the surface. Later the patient has a sensation 
in the region of the anus, followed by swelling and painful defecation. 
Fluctuation is easily observed with the aid of one finger in the rectum, 
while the other is applied externally. These abscesses are frequently 
followed by fistula. 

Rectal abscesses may be classed according to their frequency, as 
acute, chronic, or gangrenous. The acute will be attended with the 
usual symptoms of an acute abscess in any other part, only the consti- 
tutional symptoms are generally more severe. When they commence 
in the ischio-rectal or superior pelvi-rectal fossae, the constitutional 
disturbances are very great, and predominate over the local ones, which 
in the early stages are indicated by tenderness and pain only, followed 
later on by redness of the skin and oedema. It is in these latter varie- 
ties that very ^prompt treatment is necessary to obviate grave after 
results. 

The chronic variety may be months in forming, and be perfectly 
painless, even on manipulation, the only evidence of an abscess being 
a fluctuating swelling with thinning and discoloration of the skin. 
Again, its presence may be only shown by a flat, boggy, crepitating 
enlargement, which can be felt by the side of the anus. This form of 
abscess is said to be the most dangerous, as it is apt to be neglected. Tt 
takes some time to open spontaneously, and so burrows up by the side 
of the rectum to some distance, as well as under the skin toward the 
perineum, or buttock, or both. 

All acute and chronic abscesses, if left, will eventually open spon- 
taneously, and the patient then fancies his trouble is over. The cavity 
of these abscesses seldom entirely closes, but sooner or later contracts, 
leaving a weeping sinus with a pouting, papillary aperture, which may 
be situated near the anus, or far from it, and thus a fistula is formed. 

Following fevers, or in patients greatly broken down in health, a 



Diseases of the Rectum and Anus. 213 

very serious condition may arise, namely, acute gangrenous cellulitis 
around the anus and rectum, which is accompanied by low constitu- 
tional symptoms, and ends in extensive death of the tissues in those 
parts. These cases are rare, fortunately, but when seen they call for 
free incisions, to allow the escape of the sloughing cellular tissue and 
putrefying pus. 

It is not often one sees a rectum abscess early. Either the patient 
is not aware of the importance of attending to the early symptoms, or he 
temporizes, using fomentations or poultices. No good is obtained by 
the local application of iodine. The only method of treatment to be 
entertained for a moment is incision. It is certainly less damaging to 
cut into an inflamed swelling near the anus where the pus is than to 
let a day pass over after suppuration has commenced. The longer the 
abscess is left unopened, the greater the danger of the formation of 
lateral sinuses. Before any pus exists, rest, warm fomentations, and 
leeches may cut short the attack ; but such a result is very rare. I will 
here give the technique of William Allingham's method of opening an 
abscess : "The patient must be placed under an anaesthetic, as an opera- 
tion is very painful. I first lay the abscess outside the anus open from 
end to end, and from behind forward, i. e., in the direction from the 
coccyx to the penineum. I then introduce my finger into the abscess, 
and break down any secondary cavity or loculi, carrying my finger up 
the side of the rectum as far as the abscess goes, probably under the 
sphincter muscle, so that only one large sack remains. Should there 
be burrowing outward, I make an incision into the buttock deeply, at 
right angles to the first. But I must here remark that in severe 
abscesses of gangrene one should not cut away the sloughs, but let them 
separate. Removing them may cause troublesome hemorrhage, as the 
larger vessels are kept open by the indurated and inflamed tissues. 
Moreover, if on removing sloughs the surrounding inflamed tissues 
be cut into, the lymphatics, which ar.e blocked at the sloughed portions, 
may be opened, and absorption of putrid matter take place, and pyae- 
mia may result. After the incision, I syringe out the cavity, and 
carefully fill it with cotton wool soaked in carbolized oil, one part in 
twenty. This I leave in for a day or two, then take it out and examine 
the cavity, and dress again in the same manner, taking great care that 
during the healing process the cavity fills up from the bottom. If 
there is any premature contraction of the external orifice, a drainage 
tube may be used with advantage. In a remarkably short time the 
patient, recovers. The sphincters have not been divided, and the 
patient therefore escapes the risk of incontinence of faeces or flatus, 
which sometimes occurs when both sphincters are incised. 

"After treatment, to give the patient the best possible chance of 
recovery, you keep the patient on the sofa, if not in bed. I always 
think it advisable to clear out the bowels once, and then confine them 
by an astringent dose of opium, for three days ; you thus secure entire 
rest to the parts, and give every opportunity for the cavity of the 



214 Diseases of the Rectum and Anus. 

abscess to fill up. After a time the carbolized oil should be discarded, 
and lotions used containing nitrate of silver, copper, zinc, or Friar's 
balsam, which last does great good. I find boracic-acid ointment, not 
strong, or a solution of thymol, advantageous. You must be prepared 
to ring the changes between these and many other applications. 
Always remember never to stuff an abscess, but put in a little wool, 
very lightly, taking care to carry it to the bottom of the abscess cavity. 

"The question naturally arises, Why do abscesses about the anus 
usually fail to close up ? Why do they form sinuses ? There are 
doubtless several reasons, but the following is sufficient: The mobility 
of the parts caused by the action of the bowels and movement of the 
sphincter muscles, almost at every breath, and the presence of much 
areolar tissue and fat; the vessels near the rectum are not well sup- 
ported, and the veins have ho valves ; there is a tendency to stasis, and 
this is inimical to rapid granulation. We know that abscesses are 
always apt to degenerate into sinuses when situated in very movable 
places, and in any lax areola tissue, as in the axilla, neck, or groin. If 
the sinus extending from an abscess is recent, it may be lined with 
granulations, and the pus is healthy. 

" After an abscess has long existed, the discharge loses its purulent 
character. It becomes watery. The abscess has gradually contracted, 
and now only a sinus, very often formed of dense tissue, remains. 
If this sinus be laid open, you may observe that its interior resembles 
in appearance the inner coat of an artery, so glistening and smooth has 
it become. If now a probe be passed very tenderly into the sinus, 
allowing it to follow its own course, and after this is done, the finger 
be placed in the rectum, you will probably find that the probe has 
traversed the sinus, passed through an internal opening, and can be 
felt in the bowel. In this case you will have a typical, simple, com- 
plete fistula; and this is by far the most common variety, very few 
fistulas that have existed for more than three months being without an 
internal opening. 

"A fistula may be a very trivial matter, indeed, which you can 
operate upon in the out-patient's room, and send your patient home 
afterward, or it may be a really serious affair, demanding extensive 
surgical interference. I have often seen a buttock so riddled with 
sinuses as to resemble a miniature rabbit-warren more than anything 
else. 

"Fistulae may exist for years without causing much pain or incon- 
venience to the patient. I have met with many persons who have had 
rectal sinuses for ten years and upwards, and never had anything more 
done than the occasional passing of a probe, when the external aper- 
ture got blocked up, and pain was caused by the formation and 
retention of matter. 

"When the tissue around the sinus becomes very dense, there may 
be, for a long period, an arrest of burrowing, but an attack of inflam- 
mation setting up at any time will cause a fresh abscess. I am often 



Diseases of the Rectum and Anus. 215 

anxiously asked by the sufferers if a fistula can be cured without an 
operation, or, as they say, 'the use of the knife.' To this I reply that 
I have seen all kinds of simple fistula get well with and even with- 
out treatment; but these occurrences are quite exceptions to the rule, 
and should not be depended upon. 

"When fistula in children is the result of worms, which is fre- 
quently brought about by the irritation they set up, a cure may often 
De effected without the use of a knife, by adopting the following plan 
of treatment. Give them every night a powder consisting of 

I£: Calomel grs. j 

Pulv. scammon co grs. iv 

Pulv. jalapse co grs. iv M. 

"Administer the following enema at bedtime: — 

li: Liq. ferri perchlor 3 j 

Glycerine 5 j 

Inf. quassia oj 

Mix. 

"And make the child take three of these lozenges during the 
day:— 

Troch. santonini grs. ij 

"It is very advisable at bedtime to tie up the child's hands, so 
that it may not, by scratching, convey any of the ova from its anus to 
its mouth. This course of treatment should be continued for about 
one week. I have found this to be eminently satisfactory, though 
other means should be employed should it fail. 

"When the child is rid of the worms and the irritation they occa- 
sion, the fistula frequently heals. This, I think, arises from the 
greater vitality and reparative power children possess. 

"In the adult, if the fistula be simple, and the patient be unwill- 
ing to submit to any operation, certain methods may be fairly tried. 
For the last few years I have been successful, on many occasions, in 
curing simple blind externals, and even complete fistulse, by means of 
carbolic acid and drainage tubes. This mode of treatment, if carried 
out with great care and some perseverance, offers, in my opinion, the 
oest chance for the patient. I find that it is essential that the outer 
opening of the fistula should be much dilated before applying the acid 
or using tubes. The dilation can be accomplished by keeping in a 
small portion of sea-tangle for a few days, or by a small sponge tent. 
When the opening is large enough, I clean out the sinus well, and then 
rapidly run down to the end of it a small piece of wool saturated in 
strong carbolic acid with ten per cent of water. I mount the wool 
upon a stiff piece of wire set in a handle, and just roughened at the 
free end. The wool can, with a little practise, be wound tightly on 
the end of the wire, so as to be small enough to go right to the bottom 
of the sinus. I then withdraw the wire, and put in a drainage tube 
just large enough to fill the sinus, and keep it in. The interior of the 



216 Diseases of the Rectum and Anus. 

sinus is, by the acid, induced to granulate ; and, if you are successful,, 
you will find, almost day by day, that a shorter drainage tube will be 
required until the whole sinus is filled up. It may be necessary to 
apply the acid more than once, and to use other stimulants, as Friar's 
balsam, solution of sulphate of copper, or nitrate of silver, etc., but 
never strong injections. Care should always be taken to keep the 
external opening well dilated. 

"I have seen many spontaneous cures of simple fistula, and have 
also seen an ordinary examination with a probe set up exactly the 
quantity of inflammation required to obliterate the sinus." The- 
writer had one case of spontaneous cure of fistula resulting from 
passing the probe through it. 

"Most of the cases which I have tried to cure without an operation, 
have occurred in private practise. The reason is that time is generally 
a great consideration to the poor man ; he does not mind a little pain ; 
he wants to be cured as quickly as possible, and therefore prefers to be 
operated upon at once, in order to get well certainly and speedily. It 
is only the rich who can afford the luxury of three or four months' 
treatment, finding themselves, perhaps, at the end of that time in much 
the same condition as they were when they commenced. 

"Altogether, I have had about fifty cases successfully treated 
without the use of the knife, and a considerable number in which I 
failed to effect a cure after a prolonged attempt. The use of the knife 
is the encouraging method." 

EEC TO-VAGINAL FISTULA. 

A recto-vaginal fistula is one which connects the rectum and 
vagina. The sinus may be situated in any part of the septum. In 
women who have borne a number of children there may be one or 
more openings from the rectal pouch into the lower part of the vagina. 
These fistulse not infrequently result from the lesion of parturition, or 
they may be due to the same causes as ordinary fistulo-in-ano. In all 
cases where the history excludes the possibility of its being a sequela of 
parturition, the rectum should be carefully examined for stricture. 

Symptoms. — The escape of flatus and liquid fasces will contin- 
ually soil and render offensive the discharge of the vagina. 

Diagnosis. — The position and size of the fistula will be deter- 
mined by inspection, by its direction and length, and by the use of a 
probe. Where the odor of the discharge causes it to be suspected, and 
inspection does not disclose it, its presence may be revealed by 
distending the rectum with colored fluid. 

Treatment. — The operation for fistula must necessarily be depend- 
ent upon its size. When it is complicated, or is caused by strictures, 
no operation for its closure is indicated until the full caliber of the 
bowel can be restored. When the opening is small, a series of flap 
operations may be performed, closing the opening into the rectum by 
buried sutures and then stitching the flap back in place. 



Diseases of the Rectum and Anus. 217 

HAEMORRHOIDS, OR PILES. 

Haemorrhoids signifies the varicose dilatation of the veins of the 
anus, called piles. It is said that almost from time immemorial 
haemorrhoids have been divided into two varieties, viz., the external 
and the internal, often also popularly called blind piles and bleeding 
piles. And this classification is founded upon a true pathological dis- 
tinction ; for, although it may be correctly said that external piles may 
and do encroach upon the mucous membrane, and so are partially 
internal, and, further, that internal piles, by reason of frequent pro- 
lapse, become more or less external, yet in the majority of cases the 
difference is well marked, and precludes the slightest doubt as to the 
diagnosis. 

In the external form the observer will perceive that they are either 
true hypertrophies of skin, exaggerations of some natural rugae around 
the anus, or round or elongated venous-looking tumors, which are 
situated at the verge of the anus or pass up into the bowels. 

In the internal kind, you will observe that they are tumors orig- 
inating within the anus, but can be forced down outside, and even may 
have put on a pseudo-cutaneous appearance from exposure, having 
been, for more or less time, subjected to the same conditions as the 
skin. You may also find a combination of these two classes, viz., 
complicated piles, and internal piles may join hypertrophied ruga?. 

To clear up any doubt as to the true diagnosis, place the patient 
on the side, instruct the patient to draw the knees up toward the chest. 
Now, by gentle pressure, return within the sphincter-ani all the pro- 
truded part that you can, at the same time directing the patient to 
retract, or draw up, the lower gut. You will then find out what is 
redundant skin, and what is internal hemorrhoid and prolapsed mucous 
membrane of the anus. If all can be reduced, it is a case of internal 
piles. If none, it is a case of external piles. Should only a part of 
a pile be returned, and the rest remain outside, it is a combination of 
both varieties, and must be considered as internal piles, and treated 
like them. All these kinds may coexist in the same patient, and then 
they are to be treated as internal and external piles. 

External Haemorrhoids. — These affections are so prevalent that 
very few persons, either male or female, arrive at middle age without 
having in some degree suffered from them. They occur almost 
equally in the robust and the weakly, in the rich and in the poor, in the 
active and the sedentary. ~No doubt some occupations and modes of 
life conduce, more than others, to the production of external haemor- 
rhoids. Still I repeat, there is no class of society or state of consti- 
tution which can be said to be entirely exempt. 

The skin around the anus and the mucous membrane at the verge 
of that aperture are remarkably delicate in structure. They are 
also profusely supplied with nerves and small vessels. From these 
facts it arises that anything tending to irritate that region may readily 



218 Diseases of the Rectum and Anus. 

cause congestion and inflammation of the part, and result in an attack 
of the piles. 

Obstruction of the liver or portal system, pulmonary or cardiac 
affections, or anything rendering the return of blood from the rectum 
difficult, are likely to conduce to the same end. From this we can 
readily see that a great variety of causes may bring on an attack of 
piles. The following may be mentioned: Too high living, especially 
the consumption of too large quantities of meat, very coarse fare, 
indulgence in alcoholic drinks, excessive smoking, violent and pro- 
longed exercise, sedentary occupations, or exposure to wet or cold. 
Other causes are faecal accumulations, constipation, often associated 
with chronic spasms of the external sphincter, diarrhea, discharge from 
the bowels resulting from internal diseases, the pressure caused by the 
uterus during pregnancy, or uterine displacement. Again, sitting on 
damp seats, friction from clothing, excoriations and irritations, the 
neglect of proper ablutions ; this is very important ; many persons seem 
to forget that the anus requires quite as much washing as any other part 
of the body, or even more; straining, however induced, — all these are 
among the common causes, predisposing or exciting, of external 
hemorrhoids. 

We have already said that two varieties of external piles may be 
recognized. The first is the so-called hypertrophies or excrescences of 
the skin; the second, sanguineous venous tumors. When you look at 
either of these in an uninflamed state, you would think them harmless 
enough. In the one case you will observe around the anus merely a 
certain redundancy of the skin, forming little flaps or tags, more or less 
pendulous, in addition to the small radiating corrugations seen in the 
normal state. In the others you perceive blue veins, rather raised 
above the surface, and running up into the bowels, resembling, indeed, 
varicose veins. ISTow, these conditions, so innocent in their appear- 
ance, are prone, at a trifling provocation, to take on an active inflam- 
mation, and to cause the patient an amount of suffering quite dispro- 
portionate to the pathological appearance. 

There is a difference of opinion as to the formation of these 
tumors. Why, I do not understand, for the rectal veins are similar to 
veins in any other part of the body, and in like manner may become 
varicosed and inflamed. 

A rectal vein becoming varicosed is tortuous and dilated in parts. 
From some constitutional or local cause, a clotting of the blood in the 
vein may take place, giving rise to simple thrombosis, hence the tumor. 
This may remain quiet and cause no pain, but only discomfort. 
Again, inflammation may start around the vein, or in its coats, occa- 
sioning periphlebitis, or phlebitis. This is the painful kind of 
sanguineous or external pile, and may subside or suppurate. 

In rarer cases, or in other situations, a rectal vein may become 
weak at one point, and cause a small aneurism of the vein, in which 
coagulated blood is contained. 



Diseases of the Rectum and Anus. 219 

It is very advisable for all these sufferers to notice the earliest or 
rather the premonitory symptoms of one of these attacks, as by this 
knowledge it may possibly be warded off, or at all events much 
mitigated. Not infrequently a little extra eating and drinking, with- 
out any absolute excess, is the exciting cause, an indulgence in effer- 
vescing wines or full-bodied port wine, or new spirits, being especially 
dangerous. 

The earliest symptom is a sensation of fulness, or plugging up, 
and slight pulsation in the anus. There is also a tendency to consti- 
pation, inducing a little straining. This is frequently followed by 
itching of an annoying character, coming on when the patient gets 
warm in bed, keeping her awake for some time, and inducing her to 
scratch the part. In the morning the anus will be found a little 
swollen and tender, and if the patient be an observant person with 
regard to herself, she will notice after a motion a slight stain of blood. 
Now, all this may pass off with the simplest care and the slightest 
medication, but if patients neglect themselves, it will surely be the 
precursor of a more or less severe attack. The palliative treatment in 
such cases should be abstinence from active exercise, rather spare diet, 
well-cooked vegetables and fish, milk and eggs, not much meat, chicken 
or quail are allowed, no beer or spirits, and wine is not desirable. If 
the patient must take some stimulant, a small cup of black coffee, or a 
glass of light claret, Seltzer, or Vichy or Vals water, will be the best 
beverage. If the patient is a smoker, the allowance must be cut down 
below the usual indulgence. Smoking is said to cause a sympathetic 
irritation of the throat and rectum. A warm bath or a Turkish bath 
should be taken three times a week, besides washing the anus night and 
morning with warm water and castile soap. After this apply one of 
the following ointments: — 

5: Acidi tannici-glycerinum. 
Apply twice a day. 

5: Bismuth sub-nitratis 3 ij 

Hyd. sub-chlor 5 j 

Morph. acetatis grs. iv 

Vaseline ^ j 

M. Sig. : Use night and morning by anointing the anus thor- 
oughly. 

I£: Liq. plumbi sub-acetatis ^ j 

Liq. opii-sedativi J ss 

M. Sig. : One teaspoonful of the lotion to be mixed with a wine- 
glass of milk and frequently applied to the anus. This is very 
soothing. 

As to medicine, the patient may take 

I>: Pil. hyd. sub-chlor. comp grs. ij 

Ext. belladonna grs. | 

Ext. taraxaci q. s. 

M. ft. pil. j. 



220 Diseases of the Rectum and Anus. 

Or, 



ft: Podophyllin grs. \ 

Ext. nux. vom grs. ss 

Ext. belladonna grs. \ 

M. ft. pil.j. 

Sig. : Three times a day, and in the morning fasting. Take some 
effervescing citrate of magnesia, in water, every morning. 

The following draught I have found to be very useful on many 



occasions :- 



ft: Liq. mag. carb , g ss 

Potassa bi-carb 9 j 

Syrupi sennse. Z ij 

Spt. setheris not 3 ss 

Aquam ad 3 ij 

M. et sig. 

Or, 

ft: Mag. sulphas 3 j 

Potas. nitratis grs. xv 

Syrupi sennse 3 ij 

M. et sig. 

To be taken every morning after the pills have been taken during 
the day. 

If the case be neglected, and advice is not sought, active inflam- 
mation will set in, and the symptoms will be as follows: When the 
piles are formed of hypertrophied skin, the small tags will be much 
increased in size. They may be very swollen, oedematous, and shiny. 
They are exceedingly painful to touch. Sometimes they ulcerate, or 
suppuration may take place if the inflammation runs very high, and 
hence small but painful little fistulas arise. At times the oedema is 
so considerable as to extend into the bowels, and form a large swollen 
ring of skin, and everted mucous membrane all around the anus. 

In regard to the sanguineous venous hemorrhoids, they are swollen 
into ovoid or globular bluish tumors, very hard, and exceedingly pain- 
ful. They can be pinched up between the fingers and the thumb from 
the tissue beneath, and they feel as if a foreign body were there. 
Sometimes, but rarely, they can, by gentle pressure, be emptied of 
their contents ; but this proceeding is not followed by any benefit to the 
patient, as in a few hours they become larger and more painful than 
before; moreover, the attempt to empty them is extremely dangerous, 
as a clot may be discharged and fatal results ensue. These tumors 
may be simple, or two or three may be present at the same time. By 
irritation they set up spasms of the sphincter . and levator-ani muscles, 
so that they are drawn up and pinched, thus adding much to the 
patient's suffering. Just as the patient is falling to sleep, a spasm 
takes place, and wakes the patient up. In addition, there is a constant 



Diseases of the Rectum and Anus. 221 

throbbing, and the sensation as if a foreign body were thrust into the 
anus ; this excites the desire, every now and again, to attempt to expel 
it by straining, which, if indulged in, of course aggravates the pain. 
Often the patient can not sit down, save in a constrained attitude, nor 
can she walk when she coughs, as the succussion causes acute suffering. 
When the bowels act, and for some time afterward, the distress is 
greatly increased, and the patient, if not absolutely confined to bed, is 
quite incapable of attending to any business. Accompanying all this 
there is general feverishness, furred tongue, and usually constipation. 
Such, then, are the symptoms of an acute attack of external piles ; and, 
if not a serious matter, it is one of great worry and loss of time, an 
important point in these hard-working days. Moreover, one invasion 
predisposes to another. I have known many patients who periodically 
suffer what I have described; besides, the writer has suffered all this, 
and positively knows that an operation will cure the patient of these 
lesions after all other measures fail. 

Treatment. — If the patient will not submit to an operation, the 
following may be used : — 

1£: Ext opii 

Ext. belladonna aa 3 j 

M. et sig. : For external use, night and morning. 

Smear a little over the swollen parts externally, and apply a warm 
flaxseed poultice. This in many cases gives very speedy relief, and, as 
a rule, is much more efficacious than cold applications ; but sometimes 
cold applications are found to be much more soothing. In that case, 
apply the lotion of lead and milk already mentioned, or, 

1^: Liq. plumb, sub-acetat. dil J j 

Liq. ext. opii 3 iv 

Tinct. belladonna 3 ij 

M. et sig. : Apply night and morning externally. 

This is very useful. Ice may be pretty constantly applied. 

The galvanic current of electricity, anode placed on the protrud- 
ing pile, having first cocained the tumor; the cathode is placed over 
the sacrum ; give from thirty to fifty milliamperes ; seance fifteen min- 
utes; this will give relief. The tags protruding from the rectum can 
be successfully removed by electrolysis, and rest in bed, which patients 
will often submit to when they will not let a knife be used. 

Treatment to Prevent the Recurrence of Piles. — I have said that 
one attack of haemorrhoids predisposes to another. It is, therefore, 
very advisable for the patient so to live, if possible, as to ward off this 
repetition. Generally the patient should eat sparingly, and fish, poul- 
try, eggs, milk, fresh-cooked vegetables, and ripe fruit should form 
a considerable part of the diet. Spirits and beer should be avoided, 
and as little stimulants taken as possible. Very strong coffee and 



222 Diseases of the Rectum and Anus. 

highly-seasoned dishes must be abstained from. Smoking must not 
be permitted, or must be indulged in very moderately. The patient 
should take plenty of walking exercise, but the exercise should not be 
violent, nor continued to over-fatigue. She should lie down after 
exercise, instead of sitting. Never omit to wash the affected parts 
night and morning with very hot or cold water, whichever is the most 
comfortable to the patient. Lastly, the bowels should be kept open, 
acting daily. If. the latter object can not be accomplished without 
some medicinal aid, the following is a capital remedy: — 

^ Ijl: Conf. pip. nigr. 

Conf. sulph. 

Conf. seimae, aa equal parts % j 

M. et sig. 

Of this one or two teaspoonfuls may be taken in water every 
morning, or night and morning, if required. 

Another remedy is admirable, pulv. licor. comp. drs. j, taken in 
a wineglass of water, twice or thrice in a week, at bedtime, or the 
use of one of the mild purgatives I have already mentioned. A steady 
perseverance in the line of treatment I have suggested, will, in all 
probability, eradicate the haemorrhoidal tendency in many cases. 

INTERNAL HAEMORRHOIDS. 

All the causes I have mentioned as likely to induce external piles, 
tend also to the production of internal haemorrhoids ; but in addition 
we may mention diseases of the genito-urinary system, the state of 
recovery from childbirth, and hereditary influences. Although consti- 
pation is a very general cause, yet piles may occur without any consti- 
pation, and be as much of a family idiosyncrasy as any other disease. 

During pregnancy external venous haemorrhoids are frequent, 
and these may, and often do, pass away after labor, in common with 
varicosities of the leg and labia vagina. But the reverse is the case 
with regard to internal haemorrhoids. These most frequently make 
their appearance after parturition, when all the parts are relaxed, and 
uterus-involution is going on. I will not attempt to give any reason 
for this peculiarity. 

Internal piles present several varieties in appearance, position, 
structure, and other characteristics. Three broadly-marked kinds may 
be observed, viz., the capillary hemorrhoids, the arterial hemorrhoids, 
and the venous hemorrhoids; at times all perfectly distinct, at other 
times united in the same patient. 

Capillary. — This first variety is described as small, florid, rasp- 
berry-looking tumors, or rather vascular areas upon the mucous mem- 
brane, having a granular, spongy surface, and bleeding on the slightest 
touch. These piles are often situated rather high in the bowel. 

Arterial. — Arterial internal haemorrhoids may be described as 
tumors varying in size, sessile or somewhat pedunculated, attaining 
sometimes very considerable dimensions, glistening or slightly villous 



Diseases of the Rectum and Anus. 223 

on the surface, slippery to the touch, hard and vascular, with an artery, 
often as large as the radial, entering their upper part. When they are 
villous on the surface they bleed very freely, and for some reason or 
other have formed and grown very rapidly. 

Venous. — The venous is the third variety, called the venous 
internal hemorrhoid, and in this the venous system predominates. 
The tumors are often large. Sometimes they are the size of a hen-egg. 
They are bluish or livid in color, and they are hardish. The surface 
may be smooth and shiny or pseudo-cutaneous. It may be well, right 
here, to quote from Professor Kichet, of Paris, who at the Hotel Dieu 
delivered a lecture on what he termed the "white piles, " hsemoroides 
blanches, as they did not discharge blood like ordinary internal haemor- 
rhoids, but a sero-mucous fluid. The professor stated that the white 
piles are merely ordinary piles in a more advanced stage, consisting 
principally of the papillary bodies of the mucous membrane. The 
incessant discharge acts as perniciously as frequent bleeding, being 
nothing more nor less than transformed blood, and he advises them to 
be operated on in the usual way. 

Partial prolapse of the mucous and submucous membrane of the 
rectum may very much resemble but is not actually a pile. It differs 
from a pile in that there is no tumor. It is neither hard, smooth, nor 
shiny, but soft and velvety, and does not consist of hypertrophied or 
dilated arteries or veins. 

Capillary Haemorrhoids. — These are so small and so little elevated 
above the mucous surface that they give no trouble by their size, and 
rarely protrude on going to the closet; moreover, there is no pain, 
unless there be a complication of ulceration. Although they are so 
insignificant in size, the quantity of arterial blood lost from them, 
though small at each action of the bowels, is so continuous as to occa- 
sion a serious drain upon the patient's constitution. I have seen 
persons quite blanched by the losses they sustain. 

The persistent arterial haemorrhage caused by these capillary and 
also by the arterial piles is far more exhausting than venous haemor- 
rhage from venous piles. The loss of blood from the venous system 
often relieves, when the former in time always depresses. 

On examination of a patient suffering from these piles, there is 
little or nothing to be felt that is abnormal, and they can only be 
diagnosed by their symptoms and ocular inspection. These patients 
complain of frequent pains in the back and loins, also, in the male, 
in the spermatic cord and testicle. They have great lassitude, and 
not infrequently the sexual power in both sexes is interfered with. 

It is these daily small losses which are apt to be overlooked, and 
which female patients accustomed to their monthly discharges scarcely 
think worthy of mention, but which, when added to menstruation, 
becomes a serious matter, and speedily induces chlorosis and an amount 
of debility which can be combated only by removing the primary cause 
of the malady. Very tiresome constipation is usually found "attend- 



224 Diseases of the Rectum and Anus. 

ant upon this condition and often continues after the patient has recov- 
ered her general health. It is only to be overcome by the patient's 
attention to diet, exercise, and the administration of such medicines as 
give tone and gently stimulate the colon, without irritating or purging. 

I have found faradization a valuable aid to other treatment. The 
anode is placed in the rectum, and the cathode over the sacrum. Give 
the amount of current that the patient can comfortably bear without 
pain. 

I have used linseed oil and the spirits of turpentine, — one dram 
of spirits of turpentine and four ounces of linseed oil. Inject a few 
drops, with a dropper, night and morning. Keep the rectum cleansed 
with warm water and castile soap. This will cure most cases of 
capillary piles, fissures, and is beneficial to ulcers of the rectum. 
It has the advantage of being cheap, a few drops only being needed 
for each application. Fuming with nitric acid is recommended by 
some specialists for the cure of capillary piles. Carbolic acid in one 
to twenty in oil or vaseline, is very useful. Make a topical application 
once every two or three days. The following ointments for the capil- 
lary piles is a very good astringent, which is necessary for these 
conditions : — 

y 1£: Ferri. sub sulphatis 3 ss to Z j 

Vaseline E j 

M. et sig. : Use a little two or three times a day after cleansing the 
anus and rectum with warm water. 

An injection into the bowels of one dram of hamamelis twice a 
day, or the occasional application of chromic acid to the piles, is rec- 
ommended. These act as most powerful astringents, not as cauterants. 
They cause little or no pain. With these remedies cures can be 
effected in many cases where an operation is not desirable, or when a 
patient is too nervous to submit to one. 

There are many symptoms common to both the second and the 
third variety of internal haemorrhoids, the arterial and the venous 
haemorrhoids. The suffering occasioned is more directly associated 
with the condition of the hsemorrhoid itself as to inflammation or 
ulceration, and with the state of the sphintcer-ani muscles , a relaxed 
condition, such as frequently exists in women and men of lax fiber, 
allowing the protrusion of even small hemorrhoids on the slightest 
exertion. This is especially noticed in women who have borne chil- 
dren. In the earlier stages of the complaint, when piles come down 
at stool, they nearly always bleed ; but they spontaneously return within 
the sphincter after the bowels are emptied, or upon the patient resum- 
ing the upright position, or, at all events, upon lying down and volun- 
tarily retracting them, and then the bleeding ceases. Later in the 
progress of the disease, the patient is compelled to return them by 
pressure, and then they keep up. But later on, in advanced cases, 
although returned, they will not remain in place if the least exertion 



Diseases of the Rectum and Anus. 225 

is made. In this way alone they cause discomfort. They also dis- 
charge a gummy, acrid mucous, watery when constant, viscid when at 
stool, which keeps the part constantly damp, leads to excoriations 
around the anus, stains the linen, and on this account is a source of 
great annoyance to sensitive, delicate-minded persons. Generally 
after visiting the water-closet, it is some time before the patient can 
become at all comfortable; often she has to lie down, and when she 
walks about she is almost always aware of the fact that she has a rec- 
tum. She scarcely ever feels that her bowels have been properly 
relieved, and this feeling often leads to the closet, and attempts to 
procure satisfaction by straining, which ultimately aggravate the 
malady. 

The condition of the sphincter-ani muscle plays an important part 
in causing distress. If it be strong and tight, as is often seen in strong, 
muscular persons, when the piles come down they get nipped, and 
their return is rendered difficult and painful. On the other hand, if 
the sphincter is lax, the bowels are constantly coming outside on the 
slightest exertion, as in coughing, stooping, or even walking; and in 
these cases when the bowels are down, the patient can seldom retain 
liquid faeces. Constipation adds greatly to the severity of the symp- 
toms, and so also does habitual relaxation, which, by causing frequent 
protrusion, induces inflammation and ulceration of the part. 

These advanced haemorrhoids are almost always associated with 
cutaneous hypertrophies around the anus, and these being irritated by 
the discharges, become inflamed and very tender. I have seen cases 
who had excrescences or small polypoid growths studded over the 
mucous membrane around the anus. 

If an examination is made of a patient suffering from arterial or 
venous haemorrhoids, distinct tumors well be felt bulging from the 
rectal wall, with a well-marked sulci between them, and on slight out- 
ward pressure of the finger one of them may be made to protrude. If 
scratched, they bleed freely. In the arterial, the blood issues per 
sultum; in the purely venous pile it only oozes out and runs away. 
These tumors vary considerably in size, even in the same patient. 
Some are quite small, others as large as bantams' eggs. 

Differences between Arterial and Venous Piles. — The arterial 
piles are not so much dependent on constitutional causes, being more 
particularly a local disease. They are affected by any excess in diet, 
etc., and are, therefore, less amenable to palliative treatment. The 
tumors are not generally so large as in the venous pile. They have a 
great tendency to bleed, the blood being of an arterial character. They 
have not the same tendency to prolapse as the venous, and the 
sphincters, as a rule, are tighter, rendering the return of the pile more 
difficult. 

The venous piles, as I have already implied, generally result from 
constitutional causes. Constipation plays a great part both in pro- 
ducing and aggravating them. They are commonly found in women 

15 



226 Diseases of the Rectum and Anus. 

who have borne many children, and who have an enlarged or retroverted 
uterus. They often occur about the change of life. They are also seen 
in men with enlarged or indurated livers, in whom the portal system is 
constantly engorged, and the circulation through the abdominal viscera 
is obstructed. This is said to be the form the spirit-drinkers get. 

The tumors are always large. They do not bleed much, but when 
they do the hemorrhage is venous. They prolapse very considerably, 
and constantly come down upon the slightest exertion. 
* Treatment. — Operative procedure is absolutely requisite to obtain 
any permanent benefit. In patients who refuse to submit to such 
radical treatment, some of the ointments or lotions used for the 
treatment of capillary piles may be tried. 

It is in the venous kind of pile that palliative treatment is most 
likely to be successful, not in always curing the disease, but in materi- 
ally alleviating it, as the malady often depends upon uterine or liver 
affections, and a generally overloaded and congested condition of the 
system found in those who habitually eat and drink too much, and who 
take but little exercise. These causes may, to a great extent, if not 
altogether, be removed, and if they are, the hemorrhoidal disorder will 
be found to be benefited to an equal degree. 

Dr. Allingham recommends a prolonged course of Friedrichsall and 
Carlsbad waters. He also recommends the oil of sandalwood to be 
taken in conjunction with such remedies as will relieve congestion of 
the portal system, and depurate the blood generally. 

The following prescriptions are commonly used: — 

fy: Pil. hydrarg grs. jss 

Pulv. rhei grs. jss 

Ext. col-co grs. jss 

Oil juniperi , m. j 

M. et. sig. : One to be taken at bedtime. This is one dose. 
Or, 

$: Mag. sulph 3 ss 

Pot. nitratis grs. xv 

Liq. ammon. acetat 3 ss 

Liq. ext. cinch, flav 3 ss 

Dec. glycyrbizse 3 j 

M. et. sig. : To be taken two or three times a day. One dose. 

I&: Ammon. chlorid grs. iij 

Podophyllin grs. ss 

Ext. nux vom gr. \ 

Ext. belladonna gr. \ 

M. et. sig. : One pill at bedtime. One dose. 

Or, 

]J: Soda sulph 3 j 

Mag. sulph 3 ss 

Acid. nit. dil m. x 

Succi tarax 3 j 

Inf. calumb % j 

To be taken two or three times a day. 



Diseases of the Rectum and Anus. 2TI 

The patient should be careful as to her diet, which must 1 not be 
stimulating in character, and should be almost devoid of alcohol. After 
the action of the bowels, a small injection of cold water should be 
administered. In some cases hot water agrees best, injected after the 
bowels move, to thoroughly cleanse the rectum, before anointing the 
piles with astringent ointments, as follows : — 

1}: Galls nut 3 j 

Pulv. rhatany 3 j 

Ext. opii grs. x 

Ext. belladonna grs. x 

Vaseline 3 jss 

M. 

L>: Acidi tannici grs. x 

Vaseline . % j 

M. To be used night and morning. 

9: Galls nut 3 ss 

Ext. opii 3 ss 

Ex. trhatany 3 ss 

Spermaceti 3 ss 

Vaseline % ss 

M. et. sig. : To be used night and morning. 

1JL: Ferri-persulphate S ss 

Spermaceti 3 j 

M. 

li: Acidi tannici grs. xx 

Morphia sulph grs. v 

Ext. belladonna 3 j 

Ext. stramonium 3 jss 

Unguent-petrolei 3 ij 

M. 

Use per rectum, night and morning. 

Dr. David Young, of Rome, has recommended glycerine to be 
taken internally as an effective remedy in haemorrhoids, even in 
advanced cases. 

The so-called "white piles" and partial prolapse of the mucous 
membranes of the bowels, are the arterial and venous piles that have 
attempted to cure themselves; that is to say, they are hard, non- 
vascular, and do not bleed. 

The palliative treatment should be that peculiar to the species 
that happens to be predominant. Some of the astringent ointments 
already prescribed may be tried, but for a permanent cure they must 
be ligated. 

The inflamed pile or piles so commonly found in every-day 



228 Diseases of the Rectum and Anus. 

practise, that are constantly coming down and getting compressed by 
the sphincters, are those which give great pain to the patient. 

When called to a patient whose piles have just come down and 
can not be returned, proceed in this way: Place the patient on her 
face, with three or four pillows under her pelvis, to raise the hips well 
up, to allow the intestines to gravitate toward the chest, or put the 
patient in the knee-and-chest position, which in some instances may be 
better ; then apply to the pile a piece of wool saturated with a twenty- 
per-cent solution of cocaine, and allow it to remain on the pile for ten 
minutes ; then pass a well-anointed finger into the bowel, and with the 
'other hand apply pressure, trying to empty the piles of their super- 
fluous quantity of blood. In some cases where there is no more than 
one pile, hot fomentations' applied constantly, while in the knee-and- 
chest position, and a little carbolized vaseline applied after they have 
been treated with hot fomentations for five or ten minutes, will give 
relief. The pile or piles can be very gently reduced by this method. 
In some very stubborn cases it may be necessary to use cold applica- 
tions, or ice wrapped in flannel, to the part, for an hour before the piles 
can be made to pass back within the bowels. All these cases are per- 
manently cured by an operation. If they can be returned, but immedi- 
ately prolapse again, do not attempt to keep them above the sphincters, 
as it is useless and harmful. 

One of the following ointments and warm linseed poultices cover- 
ing the lint may be used : — 

ft: Unguent elemi 5 ss 

Ungt. sambrici | ss 

Bal. copaiba 3 j 

Ext. belladonna 3 ss 

M. et. sig. 

ft: Ext. belladonna 3 j 

Ext. hyosciami 3 ij 

Ext. conii 3 ij 

Vaseline ■ 3 j 

M. et. sig. 

By the warmth and the ointment, profuse suppuration is caused, 
and a separation of the slough quickly procured. f 

If the patient is much depressed, stimulants and tonics will be 
necessary, but the general treatment must be regulated according to 
the character of the constitutional disturbance. 

In uterine diseases where women are suffering from a retroverted 
or antiverted uterus, an operation is very unsatisfactory. The uterus 
should be restored to its normal position and size prior to an operation 
upon the piles ; and when this is done, the rectal affection will soon 
become a comparatively small matter. 

There are various methods of treatment for the removal of piles. 
Some of the best methods are: First, excision; second, ligature; then 



Diseases of the Rectum and Alius. 



229 



removal by clamp and scissors and cautery, applying the actual cautery 
to arrest hemorrhage. Dilatation of the sphincter muscle is a very 
popular as well as safe method in chosen cases. Removal by the 
galvanic cautery wire is also becoming useful; also removal by means 
of the screw crusher. The operator chooses the method best suited to 
his or her case. 

My advice to every person who is suffering with this malady is 
to be operated upon and be relieved, permanently, from the constant or 
periodical attacks of suffering. 




Fig. 23.— Polypi. 

Polypi. — This means a peduncled growth. Polypus was formerly 
looked upon as a very rare disease. The polypi are usually few in 
number, and in the adult it is rare to find more than one. Though 
generally of small size, they sometimes become as large as a prune, or 
even a hen's egg. The size of the growth is dependent upon the blood 




Fig. 24.— -Polypi. 

supply. It has generally been believed that polypi are much more 
frequent in children than in adults. This has not been my experience. 
This may be explained, in that children shed their polypi. The tumor 
is usually of a rounded form, and is dependent by a slender pedicle. 
Polypi is commonly situated about an inch to an inch and a half above 
the anus ; occasionally they are said to be found six inches high in the 



230 Diseases of the Uectum and Anus. 

rectum. Their most common seat is a dorsal portion of the rectum or 
posterior wall of the gut. The pedicle may be round or flattened. It 
is large and short in the fibrous variety, long and slender in the soft 
ones. 

The Soft or Gelatinous Variety. — The polypi are small vascular 
tumors, with a peduncle often two inches long. They are near the 
size of a raspberry, and resemble a small half-ripe mulberry. I had 
one case, a young girl's, where the polypi resembled a red raspberry 
more than anything else. They bleed very freely at times, and occa- 
sionally in the young cause great debility. They are said to be hyper- 
trophies of the glands of Lieberkuhn, or of the mucous follicles of 
the rectum. 

Such a growth may e*xist for a long time without causing any 
suspicion of its presence. The patient may be aware of its existence 
only when a tumor appears at the anus. It may produce a series of 
phenomena, as severe pain during defecation, tenesmus, twitching, and 
mucus, and a fleshy mass protruding from or appearing at the anus 
pelvis. Besides, there is a glairy mucous discharge, and sometimes 
blood. The general health remains good unless the hemorrhage is so 
great as to cause ansemia to be induced. 

The usual symptoms in children are frequent desire to go to 
stool, accompanied by tenesmus, occasional bleeding, with discharge of 
mucus, and a fleshy mass protruding from or appearing at the anus 
when the bowels are acting. They are most usually described by 
mothers as piles, or as "the body comes down." 

They may be dangerous when high up by causing intussusception 
of the bowels, with obstruction and death. 

Diagnosis. — The diagnosis is easy. First pass a well-anointed 
finger its full length into the rectum, and gradually withdraw it, 
sweeping the finger around the entire rectal surface. By so doing the 
finger will hook the pedicle, and your diagnosis is made. On the 
other hand, were you to examine from below upward, the tumor 
might be pushed out of reach. 

It is possible to mistake the disease for internal piles, procidentia- 
recti 2 or dysentery. An examination after an injection will clear up 
the doubt in the first two cases ; in the last, the presence of fever, the 
abdominal pain, and the appearance of the motion are sufficiently dis- 
tinctive indications as to the differential diagnosis. 

Treatment. — The treatment to be recommended is the removal of 
the growth. It is not safe to cut or tear off a polypi, as troublesome 
arterial hemorrhage may ensue. Ligature is certainly the safest 
method. The polypus should be seized and drawn down; then pass 
a needle through a small piece of the mucous membrane only, at the 
base of the pedicle. Now tie a single knot, after which surround the 
pedicle with the ligature and tie up tightly, then cut off the polypus. 
By securing the pedicle in the above manner, there is no danger of 
bleeding, or of the ligature slipping off when the bowels act. The 



Diseases of the Rectum and Anus. 231 

patient should rest in bed until the ligature separates, and I usually 
order a mild astringent draught to keep the bowels confined for three 
days (will add that I always have the bowels thoroughly cleaned out 
with some saline laxative before ligating the polypi), then I order an 
aperient, and upon the movement of the bowels the ligature will come 
away. The patient's rectum should be washed out with warm water. 
At the end of a week the patient can resume his usual work. 

POLYPOID GROWTHS. 

By polypoid growths are meant small growths protruding from 
the mucous membrane of the rectum, but not absolutely pedunculated. 
They rarely protrude outside of the anus. These growths are of great 
importance, as they occasion or ketp active several diseases of the rec- 
tum, as pruritus-ani and fissure. It is only by removal of these poly- 
poid growths that the above-mentioned ailments can be combated. 
There may be noticed two varieties, both of which must be carefully 
distinguished from warts, which chiefly affect the outside of the anus, 
and are presently to be described. One kind of polypoid growth con- 
sists of little tags of mucous membrane, with the apex pointed and hard. 

Symptoms. — It is rarely the case that patients come for consulta- 
tion about the growths themselves ; they only complain of the symp- 
toms occasioned by them, viz., discharge of the anus, which causes 
fissure or pruritus-ani. They can be felt by the finger or seen by means 
of a speculum. 

Treatment. — They should be removed by the galvanic current of 
electricity. Pass a platinum needle through the base, using the anode, 
passing the cathode through the apex, first cocaining the parts thor- 
oughly. Generally fifteen to thirty milliamperes or less is sufficient 
to turn the tags white, or they will become blanched looking, which is 
sufficient to shrink them up. Some operators do not take that trouble, 
but snip them off, and they rarely bleed much. 

WARTS. 

Warts around the anus may be the same as warts in other parts 
of the body, — sessile or pedunculated. The peduncle may be single 
or multiple, the surface smooth or branched. 

They may arise like other warts, from a natural predisposition in 
the patient, or they may follow on gonorrhoea, leucorrhoea, discharges 
during pregnancy, or, in fact, on any watery discharge. They rarely 
extend into the rectum, being chiefly confined to the parts around the 
verge of the anus. 

Treatment. — The most excellent treatment is the galvanic current. 
Put the cathode over the sacrum, and pass the electric needle just 
underneath, or within the base, of the wart, giving from ten to twenty 
milliamperes, if necessary, to turn the wart to a whitish color. It 
usually takes from one to three minutes, dependent upon the strength 



232 



Diseases of the Rectufn and Anus. 



of the current. Reverse the current for a few seconds, and remove the 
needle. Treat each wart likewise until all have been treated. The 
parts should he first thoroughly cocained with a twenty-per-cent solu- 
tion, for at least fifteen minutes, using absorbent cotton dipped in the 
cocaine and laid over the warts. I have treated as many as ten to 
fifteen at one seance. I have never had to repeat the operation. It 
takes a few days for the warts to disappear by this operation or plan 
of treatment. It is necessary to keep the anus cleansed with castile 
soap and warm water, after which apply oxide of zinc ointment until 
well. 

Most surgeons recommend the application of fuming nitric acid 
to each wart, and at the same time to scrape them off with the end of 
a wooden match. When this has been done, the acid should be applied 
to their bases. This causes little pain, and is a speedy cure. 

PROCIDENTIA RECTI AND PROLAPSE OF THE RECTUM. 

There is said to be confusion of ideas sometimes, occasioned by 
the use of the words "procidentia" and "prolapsus." The distinction is 



*5&l 




Fig. 25. — Procidentia. 



thus pointed out by Dr. Allingham: "They are very different in appear- 
ance, and hence it is most important to retain the two names, for by so 
doing we thoroughly understand what affection we are speaking about. 
Moreover, the best operative methods for obtaining a radical cure of 
the two diseases, are very different from one another. Prolapse, as 
I shall describe it, may best be treated by excision, whereas procidentia 
requires the use of actual cautery. 

"By prolapse, I mean a protrusion from the anus of a portion or 
portions of the mucous membranes, not in its entire circumference,' 
and unaffected by piles. 

"External hemorrhoids, when they come down outside the anus, 
are said to be prolapsed hemorrhoids. 

"To these two conditions only, would I restrict the term prolapse. 
They may and should be cured by removal. 



Diseases of the Rectum and Anus. 233 

"I would confine the term procidentia to a descent qf the whole 
circumference of the rectum. This may take place in three ways : — 

''First, when the entire circumference of the mucous membrane, 
or all the coats of the rectum, appear outside the anus. 

"Second, when the upper part of the rectum descends through the 
lower part, and then appears outside the anus. 

"Third, when the upper part of the rectum descends through the 
lower part, but does not appear outside the anus. 

"These two latter conditions are kinds of intussusception, but 
would better be described as forms of procidentia." 

Procidentia, when it occurs, as is represented in diagram 25, pre- 
sents the following symptoms: — 

When the bowels act, the mass protrudes, and in old cases fre- 
quently bleeds. Constipation is the usual symptom in children, but in 
the old, an "objectionable," teasing diarrhea is more commonly pres- 
ent. There is then often a discharge of mucus. In children the 
mass only, as a rule, protrudes on going to stool, but in adults it is 
down or coming down on the slightest exertion, and therefore may 
become ulcerated or inflamed. 

In very old or bad cases of procidentia, more or less incontinence 
of faeces always exists. As I have before said, there may be two rea- 
sons for this symptom : First, loss of tone in the sphincter, the frequent 
protrusion stretching these muscles so that they lose a great deal of 
their contractile power; and, secondly, the mucous membrane gets so 
altered in structure as to lose, in a great degree, its natural sensitive- 
ness. Thus, when faecal matter comes into the lower part of the rec- 
tum, the sphincters are not stimulated to action, nor is the patient 
aware of its presence. 

Procidentia varies greatly in size. It is sometimes very large. 
I have seen it in a woman larger in circumference than a foetal head, 
and seven or eight inches in length. 

In the third kind of procidentia, the symptoms are as follows: 
There is no protrusion of the mass from the anus. There is gener- 
ally obstinate constipation, unrelieved by purgatives; sensation of 
fulness in the bowels, attended with burning and tenesmus, straining 
difficulty in defecation, with occasional discharge of blood and mucus. 

Diagnosis. — The diagnosis of the first two kinds is obvious. The 
third variety is not always easy to diagnose, as the mass never appears 
outside of the anus. 

How to Examine the Patient. — The bowels having been previously 
washed out, direct the patient to stand up, introduce the finger into the 
bowel, and then, keeping the finger close to the anterior or posterior 
wall, pass it up until you meet with an obstruction, i. e., it has passed 
into the cul-de-sac; then withdraw the finger slightly, and examine 
the center of the gut until you find the orifice, into which the finger or 
a bougie may be passed for some inches, high up into the rectum, 



234 Diseases of the Rectum and Anus. 

telling the patient to bear down if the intussusception is rather far 
up in the rectum. 

Procidentia of the rectum is more often seen in children than in 
adults, although by no means is it a rare affection in women, especially 
those who have borne children. It is also seen in men of advanced 
years. Procidentia in children is much favored by the formation of 
the pelvis, the sacrum being nearly straight. All infants strain 
violently when their bowels act, even when their motions are quite 
soft. These facts, why infants or children are prone to this malady, 
are not quite understood. There is always in addition some inherent 
weakness or extraneous source of irritation present by which excessive 
straining is caused. We may mention diarrhea, often the result of 
strumous inflammation of the intestines, worms, stone in the bladder, 
phimosis, polypus-recti, etc. There are many cases, however, in which 
we can not assign any special cause, where the children are not mani- 
festly unhealthy, and no source of irritation can be detected. It is 
believed that the very bad custom of placing a child upon the chamber 
utensil, and leaving it there for an indefinite period, as practised by 
many mothers and nurses, is a fertile cause of procidentia. 

Dr. Allingham thus describes his method of returning procidentia : 
" Sometimes when a large portion of the bowel comes down, there is 
much difficulty experienced in returning it. I have found on several 
occasions that the passing up the bowel of a large, flexible bougie, so as 
to carry before it the upper part of the descending gut, is of great 
service. Gentle taxis should at the same time be used, and in this 
manner the mass can generally be returned. When the gut comes 
down, and the patient can not get it back, and does not seek assistance, 
it gets tightly girt about the sphincter, great swelling takes place, and 
sloughing may ensue. I have seen many cases of this kind, but as far 
as my experience goes, the sloughing is partial, and only the mucous 
membrane separates. After a few days' rest, with the buttocks well 
raised to favor the return of the blood, the part can be replaced, and 
considerable benefit may result. Care should be used in the applica- 
tion of ice in these cases, as it favors sphacelin, causing extensive 
sloughing, and there may be caused free secondary hemorrhage; also, 
a very intractable stricture may result. 

"Hernial Sack in Procidentia. — Directly the bowel is protruded, 
you can tell that there is a hernia also present by the fact that the 
opening of the gut is turned toward the sacrum. When the hernia is 
reduced, the orifice is immediately restored to its normal position in 
the axis of the bowel. I have seen several cases in the practise of my 
colleagues at St. Mark's ; the condition is therefore not very uncommon, 
but I have never found it in children." 

Treatment in Children. — Palliative treatment is generally suc- 
cessful. It should first be addressed to the removal of any source of 
irritation; this accomplished, a cure is speedily effected. When no 
source of irritation can be discovered, the general health must be 



Diseases of the Rectum and Anus. 235 

attended to. The child should never sit and strain at stool. The 
motion should be passed lying upon the side at the edge of the bed, or 
in a standing position, and the buttock should be drawn to one side, 
so as to tighten the anal orifice while the fseces are passing. This 
device you will find to be very useful. It is recommended in Druitt's 
surgery. 

When the bowels have acted, the protruded part ought to be well 
sluiced with cold water, and afterward with a solution of — 

1$: Alum sulph o j 

Dec. quercus J j 

M. et. sig. 

To be increased in strength if it can be borne ; or an infusion of matico, 
Kremaria, or weak carbolic acid, should be applied with a sponge. 
The bowel must then be returned by gentle pressure, and the child 
should remain recumbent for some little time, lying upon its face, on 
a couch, with its neck turned so its face is made comfortable. If there 
be any intestinal irritation, small doses of — 

$: Hyd. C. creta grs. ij to grs. iij 

Pulv. rhei grs. iij 

M. et. sig. 

Give this at bedtime. It may be necessary to give steel-wine two 
or three times in the day, after meals, for a tonic. When the child is 
very ill-nourished, cod-liver oil does much good. The diet should be 
nourishing and digestible; well-beaten eggs, flavored with nutmeg, or 
something palatable, should be given twice a day. Milk fresh from 
the dairy is better than that that has stood too long before using. 

If mild measures do not succeed, Allingham, who has had a very 
wide experience in all diseases of the rectum, recommends the appli- 
cation of strong nitric acid as being the best remedy. "Chloroform is 
administered, and the protruded gut well dried. The acid must be 
applied all over it, care being taken' not to touch the verge of the anus 
or the skin. The part is then oiled and returned, and the rectum 
stuffed thoroughly with wool. After this, a pad must be applied out- 
side the anus, and kept firmly in position by adhesive plaster, the but- 
tocks being by the same means brought close together. If this pre- 
caution be not adopted, when the child recovers from the chloroform, 
the straining being urgent, the whole plug will be forced out, and the 
bowels will again protrude. When the pad is properly applied, the 
straining ceases, and the child suffers little or no pain. I always order 
a mixture of aromatic confection, with a drop or two of tincture of 
opium, so as to confine the bowels for four days. It may be given 
every eight or ten hours, if necessary, to relieve the straining and keep 
the child quiet. At the end of four days, the strapping is removed, 
and a teaspoonful of castor-oil is given. When the bowels move, the 
plug comes away, and there is no descent of the rectum. 

"I have had experience in this treatment in a great many cases, 



236 Diseases of the Rectum and Anus. 

and I have never known it to fail if properly carried out, and only on 
two occasions have I had to apply the acid more than once. The result 
is, also, not a temporary but a permanent benefit. 

"Procidentia in the adult is very much more unmanageable, and 
is supposed in many instances to be quite incurable. Sometimes a 
procidentia occurs conjointly with internal haemorrhoids. In this 
case, when the procidentia gut is returned, there still remains outside 
the anus a ring of haemorrhoids, or loose and thickened membrane. I 
may say that when the procidentia is small, it will almost certainly be 
cured by ligature of the pile. This was clearly shown by Mr. Hey, 
of Leeds, years ago." 

Treatment in Adults.— As a curative means, "thermo-cautery is 
employed. Three or four of the tissues are cauterized. The patient 
is given bismuth or opium to produce constipation, which is overcome 
on the eighth or ninth day by a light purgative." — Edward Mont- 
gomery, M. D. 

Dupuytren produces cicatricial narrowing of the anus, by remov- 
ing with curved scissors from two to six radiating folds to the right and 
left of the anus. 

Duret removed from the posterior wall of the rectum a triangular 
piece of the mucous membrane, the base of which included a part of 
the sphincter. 

Schwartz excises a large piece of the anterior wall of the rectum 
and the anus. 

Mikuliez shortens the rectum in the following manner : The intes- 
tine is emptied by an injection, and opium is administered to limit 
peristalsis. The patient is placed in the dorsal position, and the field 
of operation is rendered antiseptic. At a point from two-fifths to 
four-fifths of an inch from the anus, the external cylinder is divided in 
its anterior half. The next step consists in incising, transversely, the 
posterior half of the external cylinder, layer by layer, from three-eighths 
to six-eighths of an inch from the margin of the anus. Sometimes, 
upon reaching the peritoneum a hernia of the small intestines will be 
perceived, and will need to be reduced. Should the sphincter prevent 
reduction, the muscle may be cut and the peritoneal fold united. The 
bowel is then incised, layer by layer, the vessels met with being tied, 
and the two edges united by the uninterrupted sutures carried through 
all the coats, threads being left long enough to serve to steady the 
rectum the remainder of the operation. The dissection and suturing 
of the posterior half are next performed, all the sutures are cut short, 
and the mass is powdered with iodoform and returned into the rectum. 

An operative procedure called "rectopexy" was performed by 
Verneuil. It consists of three steps, as follows : An incision is made 
about an inch and a half long upon each side of the anus, extending 
obliquely from above downward and backward. The portion of the 
anal circumference included between the anterior extremities of the 
incisions corresponds to the portion to be contracted. They begin at 



Diseases of the liertum and Anus. 237 

the point of junction of the skin and mucous membrane. From their 
posterior extremities start two other small incisions, which meet at 
the coccyx. The included flap is dissected from behind forward, the 
posterior fourth of the sphincter being removed at the same time, care 
being taken not to injure the rectal wall. The second step consists 
in the insertion of four sutures of silkworm gut, introduced trans- 
versely with a curved needle, into the posterior wall of the rectum, with- 
out injuring the mucous membrane. When the sutures are drawn 
toward the sacrum, it will be seen that the cavity of the rectum is made 
decidedly narrower, and that the posterior wall is fixed to a certain 
extent. To make this result permanent, a needle is introduced through 
the skin near the sacro-coccygeal articulation, about an inch from the 
median line, and is brought out in the ano-coccygeal wound. The cor- 
responding end of the upper suture is then passed through the needle's 
eye, and is drawn out by withdrawing the needle, which is then intro- 
duced at a corresponding point on the opposite side, and the other end 
is secured. The other sutures are treated in the same way, being 
tightly drawn and tied one after the other. The third step consists in 
excision of the cutaneous flap which has been dissected, and is adherent 
by its base. A few sutures are inserted in the vicinity of, and a little 
higher than the anus. This operation affects only a limited portion 
of the rectum, either in length or in height. 

Allingham, of St. Mark's Hospital, London, speaks very highly 
of Dr. Van Buren's (of New York) plan of treatment. He says: 
"I have operated by his method in twenty-six cases, with most satis- 
factory results ; but I have also seen several patients in which the 
procidentia was situated high up in the bowels, and was only able to 
alleviate their sufferings by directing them to pass a bougie, prepara- 
tory to their bowels acting, which should be performed in the recum- 
bent position." 

Dr. Van Buren's method is as follows: "The patient is anaesthe- 
tized, and if the part be not quite down, it can readily be drawn fully 
out of the anus by the vusellum. I then, having the intestines held 
firmly out, with the iron cautery at a dull red heat, make four or more 
longitudinal stripes from the base to the apex of the protruded intes- 
tines, taking care not to make cauterization as deep toward the apex 
as at the base, because near the apex the peritoneum may be close 
beneath the intestine, while a deep burn near the base is not dangerous. 
I take care to avoid the large veins, which can be seen on the surface 
of the bowels. If the procidentia be very large, I make even six 
stripes. I then oil, and return the intestine within the anus. Having 
done this, I partially divide the sphincters on both sides of the anus, 
with a sawing motion of the hot iron, and then insert a small por- 
tion of oiled wool. From the day of operation I never let the patient 
out of bed for anything. The motions are all passed lying down; 
consequently the part never comes outside. If the wound has not 
thoroughly healed in a month, I continue the recumbent position for 



238 Diseases of the Rectum and Anus. 

two weeks more, by which time it very rarely happens that all is not 
healed. The patient can then rise and get about; but still, for some 
time, I enjoin that evacuation of the motion should be accomplished 
lying down. The reason for the success of the treatment is simple 
enough. When the burns are all healed, the bowels, by contraction of 
the longitudinal stripes, are drawn upward, and circumferential dim- 
inution also takes place. Should one operation not succeed, a repeti- 
tion of the burning must be tried. With this method of treatment I 
have had great success, many persons being quite cured, while others 
have been greatly benefited, so as to be able to work by only wearing a 
jfad of cotton wadding." 

ULCERS AND STRICTURES' OF THE RECTUM WITH AND WITHOUT 

ULCERATION. 

Ulceration of the rectum extending above the internal sphincter, 
and frequently situated entirely above that muscle, is not a very 
uncommon disease. It inflicts great misery upon the patient, who dies 
of exhaustion unless extraordinary means are resorted to. In the 
early stages of the malady, careful, rational, prolonged treatment is 
often successful, and the patient is restored to health. Ulceration of 
the rectum can be mistaken only for malignant disease. But when the 
finger is well educated, only occasionally can there be any error com- 
mitted in diagnosis. As the early manifestations are fairly amenable 
to treatment, it is of the utmost importance that the disease should be 
recognized early. Unfortunately, it is rarely so. The symptoms are 
obscure and insidious, the suffering at first but slight, and thus the 
patient deceives, not only herself, but her medical attendants, by the 
little heed that is usually given to the complaint. 

Varieties of Ulcerations. — There are various causes of ulceration 
of the rectum proper, and each variety gives rise to a specific kind of 
ulceration. These, for practical purposes, may be divided into tuber- 
cular, dyesnteric, and syphilitic. The history in the majority of 
cases alone will indicate which kind of ulceration the patient is suffer- 
ing from, and too much reliance should not be placed upon the feel 
or character of the ulcer. 

Symptoms. — In the majority of these cases the earliest symptoms 
are morning diarrhea, and that of a peculiar character. The patient 
will tell you the instant that she gets out of bed that she has an urgent 
desire to go to stool. She does so, and the result is not satisfactory. 
What the patient passes is a little wind and a little loose motion, some- 
times resembling coffee grounds, both in color and consistency. Occa- 
sionally the discharge is like the white of an unboiled egg, or a jelly- 
fish; more rarely there is matter. The patient in all probability has 
tenesmus, and does not feel relieved. There is some burning and 
uncomfortable sensation, but not actual pain. Before the patient is 
dressed, she again has to seek the closet. This time she has more 



Diseases of the Rectum and Anus. 239 

motion, often lumpy, and occasionally smeared with blood. It may 
happen that after breakfast, hot tea or coffee having been taken, the 
bowels will again act. After this she feels all right, and can go about 
her business for the rest of the day, only, perhaps, being occasionally 
reminded by a disagreeable sensation that she has something wrong 
with her bowels. Not always, but at times, the patient has morning 
diarrhea, attended with griping pain across the lower part of the 
abdomen, and great flatulent distension. 

When a physician is called and consulted, the case, in all probabil- 
ity — and quite excusably — is considered one of diarrhea of a dysen- 
teric character, and treated with some stomachic and opiate mixture 
which affords temporary relief. After this condition has lasted for 
some months, the length of this period of comparative quiescence being 
influenced by the seat of the ulceration and the rapidity of its exten- 
sion, the patient begins to have more burning pain after an evacuation ; 
there is also greater straining, and an increase in the quantity of dis- 
charge from the bowels. There is now not so much jelly-like matter, 
but more pus, more of the coffee-grounds discharge, and blood. The 
pain suffered is not very acute, but very wearying, described as like a 
dull toothache, and it is induced now by_much standing about or walk- 
ing. At this stage of the complaint, the diarrhea comes on in the 
evening as well as in the morning, and the patient's health begins to 
give way, only triflingly so, perhaps, but he is dyspeptic, loses his appe- 
tite, and has pain in the rectum during the night, which disturbs his 
rest. The patient also has wandering pains, and apparently anomalous 
pains in the back, hips, down the leg, and (if a male patient) some- 
times in the penis. There are also in the latter stages of the disease, 
marking the existence of some slight contraction of the bowels, alternat- 
ing attacks of diarrhea and constipation, and during the attacks of 
diarrhea the patient passes a very large quantity of faeces. These 
seizures are attended with severe colicky pains in the abdomen, with 
faintness, and not infrequently sickness. 

Patients suffering from ulceration are very liable to attacks of a 
low form of peritonitis, attended with considerable abdominal pain, 
often intense for a short period. There are generally one or more 
spots that are tender on pressure. There is tympanitis, often vomiting, 
especially on first resuming the erect position in the morning, and gen- 
erally the pain is brought on by standing or moving about. These 
attacks are sure to end in diarrhea. 

Examination. — On examining these cases of ulceration of the rec- 
tum, various conditions may be noticed, according to the stage to which 
the disease has advanced. In the earlier period, you may often feel 
ulcers situated about one and a half inches from the anus, varying in 
shape, some an inch long by half an inch wide, surrounded by a raised 
and sometimes hard edge. There is acute pain caused on touching 
them, and they may be readily made to bleed. 

With a speculum the ulcers can be seen distinctlv. The base of 



240 Diseases of the Rectum and Anus. 

these ulcers is grayish or very red and inflamed looking, or sloughing, 
the surrounding mucous membrane being probably healthy. In the 
neighborhood of the ulcers may often be felt some lumps, which, when 
syphilitic, may be either gummata or enlarged rectal glands. This is 
the stage when the disease is often curable. Later in the progress of 
the malady, you will observe deep ulcers with great thickening of the 
mucous membrane, often roughening to a considerable extent, as though 
the mucous membrane had been stripped off. At this stage you gener- 
ally notice, outside the anus, swollen and tender flaps of skin, shiny, 
and covered with an ichorous discharge. These flaps are commonly 
club-shape, and are met with also in malignant disease ; but in the early 
development of the disease no ulceration is found near the anus, nor at 
the aperture. It is said that a large majority do not commence by any 
manifestation at the anus, such as growths or sores. Occasionally, a 
fissure may be the first lesion, and the ulceration extend from the wound 
made in the attempt to cure it. This is, however, said to be an excep- 
tion to the rule. So definite is this external appearance in long-standing 
disease, that one glance is sufficient to enable an expert to predicate the 
existence of either, cancer or severe ulceration. These external enlarge- 
ments are the result of the ulceration going on in the bowels, and the 
irritation caused by almost constant discharge. The ulceration may be 
^ confined to a part of the circumference of the bowel, or it may extend 

all around, and for some distance up the rectum. It will also, probably, 
have traveled downward close to the anus, and then the pain is sure to 
be very severe, because the part is more sensitive and more exposed to 
external influences and accidents. 

When the disease has reached this stage, stricture, and most prob- 
ably fistula, will be present, and not infrequently perforation of the 
, bladder into the vagina or into the peritoneal cavity may occur. 

The state of the patient is now most lamentable ; his or her aspect 
resembles that of a sufferer from malignant disease, and no remedy, 
short of colotomy, offers much chance of even temporarily prolonging 
life. You may relieve these patients, but can rarely do more. A cure 
can scarcely be expected. Ulceration will utterly destroy both the an&l 
sphincters, so that the anus is but a deep, ragged hole. In the earlier 
stages of ulceration, from whatever cause save cancer, treatment care- 
fully selected, judiciously varied, and persistently carried out, may do 
much good, and in favorable cases even effect a cure; but the patient 
must have faith in the surgeon, and be prepared to submit to a long- 
continued watching when much improved. If the sufferer runs about 
from one doctor to another, his fate is sealed, as he gives neither himself 
nor the surgeon a chance. 

Palliative Treatment. — In all stages of ulcerations, the patient 
should rest in the recumbent position, and a fluid diet should be used. 
Milk should be the essential element in such a diet. Many patients 
can be cured with a very little medicine. Every third day touch the 
ulcers with slight caustic. Nitrate of silver, ten to twenty grains to 



Diseases of the Rectum and Anus. 241 

the ounce, is very good for this purpose. Use bismuth and a little 
opium to control straining and diarrhea, and rest on a sofa during the 
day. I have been successful in using a mild current of galvanism. 
Have a small electrode to fit the size of the ulcer, wrapped with absorb- 
ent cotton, dipped in ten per cent of cocaine ; place the positive over 
the sacrum or in the vagina, and the negative in the base of the ulcer, 
using great care not to press too hard with the electrode, lest you do 
injury. Give about five milliamperes. Seance from a half to two 
minutes is sufficient to stimulate the base of the ulcer to heal; then 
you may touch the ulcer with a ten-per-cent solution of nitrate of silver. 
The day following this treatment, the patient may inject with a dropper 
a few drops of the following lotion : — 

(l: Chian turpentine 3ss to j 

Linseed oil giv 

Misce. 

Use night and morning, the days between the application of the 
nitrate silver solution. After each movement of the bowels, the rectum 
should be washed out with warm water. I have never had a case of 
simple ulceration of the rectum, not malignant, that I have failed to 
heal since I have used the galvanic current of electricity to aid the 
caustic solution, etc. 

The edges of old chronic ulcers, I may add, that are hard and 
unyielding, you will find will soften up as the ulcer heals from its 
base, and this will allay contraction and alleviate pain. If the ulcer 
is one of the bleeding variety, the anode, or positive pole, should be 
made active to check the bleeding, and is to be applied in the same 
manner as above described. 

A very good powder to be blown into the ulcer through a quill or 
glass tube, or an insufflator such as used for flea powder, is : — 

II: Hydrarg. chlor. mite. . ,Tj 

Bismuth sub-nit > 3ij 

Mi see. 

Puff a little into the base of the ulcer once a day or every other 
day, as needed, to promote healing. 

Allingham recommends the following as most efficacious: — 

#: Bismuth sub-nit 5ij 

Hydrarg. chlor. mite 9ij 

Glycerine 3ij 

Morph. acetat grs.ij 

Vaseline gj 

Mi see. 

This is a very sedative application, and sores seem to be benefited 
by it speedily. 

Subacetate of lead, belladonna, and opium will be found to be 
excellent. All sorts of astringents may be employed to suit each indi- 

16 



242 Diseases of the Rectum and Anus. 

vidual case: Khatany, Friar's balsam, zinc, permanganate of potash, 
sulphate of copper, half to one grain to the ounce of water; touch the 
base of the ulcer daily, then wash out the rectum afterward, and inject 
a bit of oxide of zinc ointment, with an ointment introducer. 

Fuming nitric acid, or strong carbolic or chromic acids, are favorite 
remedies with many surgeons, and are potent remedies, if carefully 
applied under certain conditions. They are said to often allay pain 
and start healing processes afresh, but they are "double-edged" weapons,, 
and should be used with great discretion and with a distinct object in 
v^iew. 

li: Cocaine .' = grs xvii 

Lanaline , Jss 

Misce. 

This will greatly allay pain and irritation in these cases. 

When the ulceration is tubercular, all treatment is extremely 
unsatisfactory, but by attention to the above details patients may be 
greatly relieved. 




Fig. 26. — Improved American Ointment Introducer. 

The screw A being removed, the box B is to be filled with the ointment. On introducing the instru- 
ment into the rectum, and turning the screw, the ointment passes out of 
the apertures, as shown at C. 

The rectum should be washed with a little peroxide of hydrogen, 
then rinsed with warm water, and a little iodoform puffed into the base 
of the ulcer. At bedtime inject a half teacupful of flaxseed tea, with 
about ten grains of boracic acid, high up into the rectum, and retain it. 
The patient should occupy a warm, sunny room, well ventilated all the 
time, and must avoid drafts. Wear warm flannel next to the body. 
Good tonics and small doses of arsenic are useful in all consumptive 
cases. 

Syphilitic ulcers require, in their early stages, a thorough course 
of mercury; but when the disease is of a tertiary variety, large doses 
of iodide of potassium and tonics, with changes in climate, afford the 
only hope of improvement. 

STRICTURE OF THE RECTUM WITHOUT ULCERATION. 

This condition is said to be somewhat uncommon. It is supposed 
that inflammation of the submucous tissue produces a deposition, and 
besides this, or resulting from this, there are spasms. I have seen 
strictures of the rectum so tight that I could not get the end of my 



Diseases of the Rectum and Anus. 243 

little finger into them, but when the patient was well under the influ- 
ence of chloroform, I have been able to pass one or two fingers through 
easily. The inflammation may be induced by passage of very dry and 
hardened faeces, though this condition may obtain for years, as it often 
does in old people, without producing stricture. The most character- 
istic feature of stricture is the passage of numerous very small, broken 
pieces of faeces, it having no actual form, and looseness often alternating 
with this lumpy condition. The discharge in simple stricture is like 
the white of an egg or a jellyfish, and is passed when the bowels first 
act. There is no coffee-ground-looking discharge so constantly seen in 
ulceration, nor is there any morning diarrhea which we get in that com- 
plaint. There is very rarely any pain experienced in the bowel itself ; 
the symptoms are more or less referred to parts, notably, if in a male, 
the penis, perineum, bottom of the back, thighs, beneath the buttocks, 
and occasionally the stomach. Fortunately, strictures of the lower 
bowels are generally in sight and within reach, but occasionally they 
are found high up in the sigmoid flexure, or still more distant from 
the anus. 

Symptoms. — Without ulceration the symptoms are straining and 
difficulty in discharging the motion. It is stated in some works that the 
stools are long, thin, and pipe-like. Spasms of the sphincter, enlarged 
prostate gland, and tumors of the pelvis much more frequently give 
rise to flattened-shaped and thin and ribbon-shape motions, and are 
expelled with marked difficulty. 

Allinghams Method for Examining Stricture. — Vulcanite balls of 
different sizes are used, mounted on pewter stems, with flattened han- 
dles. They are easily bent into any form. They will bend in the 
bowel, and by their use you may make certain of detecting a stricture; 
for when they pass, or are gently withdrawn, the ball is felt to come sud- 
denly, and perhaps with some difficulty, through the constriction; its 
length can also be approximately measured. 

Allinghams Method of Treatment. — If the stricture and ulceration 
exist, the complication must be treated as described in the preceding 
chapter. At the same time the stricture may be treated by the use of 
bougies ; but to do any good, the greatest gentleness must be practised 
by the surgeon. Pain ought not to be caused, although considerable 
discomfort can not, in most cases, be avoided. Too large-sized bougies 
are unnecessary. Keep below the size that can be well borne, rather 
than at all above it. It is not safe for a patient to treat herself by the 
use of a bougie, as there are recorded cases where they have thrust the 
instrument through the rectum wall, causing peritonitis and death. In 
cases of stricture, when there are great spasms, with a small amount of 
organic disease, much good may be done by the use of bougies. Before 
passing the bougie, it is best to inject the bowel with some sedative, as 
opium and belladonna, and to use some stiff lubricant on the bougie, 
such as blue ointment. If the instrument can not be quickly passed, 
it is better not to persevere, as irritation will be set up and damage done.' 



244 Diseases of the Rectum and Anus. 

Once set up spasms, and all your endeavors may be frustrated. The 
stricture must, as it were, be surprised. Any forcible dilatation in 
these cases is to be avoided. You may tear or split the stricture with 
Todd's dilator, but you are more likely to get ulceration than perma- 
nent benefit to the stricture. On the same principle I should not cut, 
even in the slightest degree, any constriction where no ulceration 
existed, save in cases which I will describe. If the stricture is high 
up, the use of Todd's dilator is dangerous. I have seen profuse hem- 
orrhage follow its use; and the bowel might be torn, to the injury of 
the peritoneum, especially in women. In these cases I am also of the 
opinion that retaining a bougie or tube any length of time is not usually 
advantageous. You may produce ulceration, and if this be done, you 
will perhaps irretrievably damage your patient. Gentle dilatation, 
very gradually increasing the size of the instrument, is the only safe 
treatment. The conical bougie is a good form, as gentle pressure 
induces this to enter the stricture more easily; but you should never 
cause pain, and you may be sure that if blood or mucous passes after 
your manipulations, your patient will have little to thank you for. 

In obstinate cases its daily use has, in my more recent experience, 
been followed by greater permanent good. Still, in this matter every 
case must be judged on its own merits, bearing in mind the axiom, 
"JSTever irritate." 

Annular strictures are so resilient that even if dilated to their 
fullest extent, they soon return to their previous state of contraction. 
It is in these cases alone that it is considered advisable to operate by 
incision, which is recommended to be only superficial, and dilatation 
should be commenced on the day following the operation. 

When the stricture is well dilated, the patient generally experi- 
ences the greatest amount of relief. There is no more straining at 
stool. Comfortable, good-sized motions are passed, and many anom- 
olous symptoms vanish. One drawback is the rapidity with which all 
strictures are apt to return. The patient should not be long without 
having the bougie passed, and certainly, as soon as any of the old symp- 
toms recur, at once obtain treatment. If this advice is acted upon, but 
little fear need be entertained of permanent dangerous relapse. 

For bad ulcerations, stricture, and fistula an operation is required, 
of which I will not go into the details, as such cases belong to gynae- 
cology. 

Cancer of the rectum, which I will not discuss, is entirely surgical. 

CONSTIPATION, OBSTIPATION, COSTIVENESS. 

Definition. — Sluggish action of the bowels. Many able and inter- 
esting papers have been written upon the medical treatment of this com- 
mon and troublesome complaint, for it often greatly affects the consti- 
tution of the patient, making her dull and nervous, deranging the 
digestive functions, and thus giving rise to very severe reflex symptoms. 
]STo doubt ill health may be the cause of constipation ; but, on the other 



Diseases of the Rectum and Anus. 245 

hand, constipation may be the primary cause of ill health, for retained 
faeces poison the blood, and then the body is illy nourished ; therefore 
it is certain that for the cure of constipation the system should be 
speedily relieved of the poisonous matter. 

Etiology. — The intestinal contents are forced onward as the result 
of peristalsis. From twelve to twenty hours are necessary for their pas- 
sage from the caecum to the anus, although but four hours are required 
for their journey from the pylorus to the caecum. When paristalsis is 
checked by atony of the muscular coat, from congenital weakness or 
acquired degeneration, by deficient nervous excitability, or by peculiar- 
ities of the contents, persistent constipation is the result. Congenital 
weakness may be the cause of the enormous enlargement of the colon 
which is at times seen in young children, and which persists, despite the 
inducing of free evacuation by means of appropriate treatment. 
Acquired degeneration of the muscle is of frequent occurrence in chronic 
catarrhal enteritis, in chronic peritonitis, and in amyloid disease of 
the intestines. Deficient nervous excitability may be due to organic 
disease of the brain or spinal cord, or to derangement, as in neurasthenia, 
hysteria, or to local affection of the intestines, as chronic passive con- 
gestion or intestinal catarrh, and in certain forms of insanity. 

The excitability of the nervous apparatus of the intestines varies 
in individuals, and is weakened by sedentary habits and negligence. 
The intestinal contents become abnormal, and cease to produce the nec- 
essary excitation, both from an excess and from a diminution of veg- 
etable constituents. A deficiency of liquids, whether due to a dry diet 
or to profuse sweating, as in excessive muscular work or fever, is of 
marked importance in the causation of constipation ; but an abundance 
of milk in some persons produces this result. Muscular spasms in the 
lower part of the rectum, oftenest excited by a painful fissure in the 
anus, and sometimes by ulceration of the mucous membrane, a retro- 
flexed uterus, or a displaced ovary, at times prove a cause of obstruction. 

Symptoms. — The effects of habitual constipation vary extremely 
m persons of nervous temperament. Some complain of headache, diz- 
ziness, mental sluggishness, depression of spirits, wakefulness, loss of 
appetite, and a coated tongue. 

The nervous symptoms are due to the absorption of the toxic prod- 
ucts of decomposition in the intestines. Faeces and putrefactive bac- 
teria are, however, the normal contents of the large intestines, in which 
the faecal retention takes place, and there is no exact evidence that any 
undue absorption of putrefactive products occurs. 

The tendency of prolonged constipation is to the accumulation of 
faeces, resulting in faecal impaction. Increasing distension of the 
abdomen takes place, and distended coils of intestines can easily be 
felt, especially in thin people. The accumulated faeces can be felt in 
the rectum or through the vagina. The accumulation takes place in 
the sigmoid flexure, descending colon, and caecum, and may be present 
in various parts of the intestines, which can also be felt through the 



246 Diseases of the Rectum and Anus. 

vaginal wall. The local effect of the faecal tumors varies considerably. 
The impaction of the faeces in the rectum usually gives rise to frequent 
distress, from constant desire for evacuation, although only a small 
quantity of slimy matter escapes. In consequence of the pressure of 
the mass upon the wall of the rectum, there is passive congestion, indi- 
cated by piles and leucorrhoea, or pain when the nerves of the pelvic 
plexus are compressed. Impacted fasces elsewhere in the large intes- 
tines may prove uncomfortable from their weight and mobility, and 
may be mistaken for an abdominal neoplasm. It is said that ulcera- 
tion of the caBCum rarely results from the presence of faeces in this part 
of the bowel, but painful tumors in the right iliac fossa may be due to 
the association of appendicitis with faeces in the caecum. Retention of 
scabalae in diverticula of the colon may be followed by an inflammation 
of the wall, extending to the peritoneum or into the meso-colon. Faecal 
retention in the sigmoid flexure is said to be an important element in 
the production of twist of this part, by elongation of the loop, resulting 
from the long-continued traction, and partly because the weight of the 
loop facilitates its turning. 

Diagnosis. — The diagnosis of chronic constipation is usually read- 
ily made by the history of the case, and from the effect of treatment. 

One daily evacuation of the bowels is the custom of most healthy 
adults. Exceptional persons are found in whom one. movement every 
three or four days is considered to be normal. It is also important to 
bear in mind that frequent movements of the bowels and abundant slimy 
discharges may be associated with and result from chronic constipation. 

Treatment. — First remove the cause. Medical treatment is to be 
avoided if possible. The faradic current of electricity should be per- 
sistently used for some length of time. The person can be taught its 
use, and it is one of the most valuable aids to relieve constipation, when 
properly applied. ( See article on electricity. ) 

Sedentary habits are responsible for constipation in many persons ; 
also postponing going to morning stool will produce constipation. 
Exercise should be enjoined, open-air exercise, if possible, gymnastics 
along with the general exercise, which should be encouraged enough to 
get the person in good muscular condition, and should be associated 
with movements which are especially adapted to strengthen the abdom- 
inal circulation. Many of the so-called "Swedish movements" are val- 
uable for this purpose. Massage is especially useful in this condition. 
Some writers recommend the patient lying on the back, and rolling 
around and around on the abdomen daily, for ten to twenty minutes, a 
ball of heavy wood or iron, using care not to get exposed, and to avoid 
a too rigorous use of this method. The habit of defecation at a certain 
time every morning should be practised. The morning hour, for most 
persons, is the most convenient from a medical standpoint. The special 
time of day does not matter, though the daily regularity is essential. 

A glass of cold water on rising in the morning is considered to 
be a very useful aperient for many persons, instead of the use of fluids 
in small amounts, which is frequently the case. The habit of free 



Diseases of the Rectum and Anus. 247 

water-drinking should be formed, with the view that the intestinal, as 
well as the other secretions, will be rendered more abundant. The 
patient should not drink ice-cold water, as this is very deleterious, espe- 
cially when there is chronic gastric catarrh or atony of the digestive 
organs. Many delicate women can drink hot water in large quantities ; 
a pint or more before meals is found to be very useful for this purpose. 
At bedtime, as well as upon rising in the morning, the person troubled 
with habitual constipation should drink from eight to sixteen ounces of 
water. He will find it often distinctly effective in promoting morning 
evacuations. 

Each individual must have food adapted to the case. The law 
is, "The greater amount of residue incapable of digestion in the food, 
the greater is its laxative influence." Laxative articles of food are 
fresh or dried fruits, all green vegetables, and grains ground entire, 
without separating the hull from the starchy interior, such as cracked 
oats, rolled oats, etc. ; these stand first ; but with some, however, cracked 
or rolled wheat is a superior laxative, as it is less digestible than rolled 
oats. Graham bread made of unbolted flour is much superior to white 
bread ; rice is not considered much of a laxative. 

Sugars, and substances containing them, are laxative, although 
they are digested. Oils, especially vegetable oils, such as that of olives, 
are mostly laxative, and, when they can be digested, are a valuable addi- 
tion to diet. Trial in each individual case affords the only test. Two 
tablespoonfuls of sweet-oil given after each meal are very beneficial in 
obstinate cases. Some writers advise a tablespoonful of whisky to be 
taken with the oil. Half a cup of pure black coffee, taken with olive- 
oil, after meals, is very efficacious in most cases. 

The difficulty in food management of constipation is that, in most 
cases, the condition is so often associated with feeble digestion, and 
that to digest food containing a large amount of indigestible matter 
is beyond the power of the patient. The diet must be carefully regu- 
lated to suit each case. I have found that New Orleans molasses, tw>j 
parts, and common brown sugar, one part, made into candy, with a little 
fresh butter, and eaten before going to bed, is a very good laxative for 
children, and for adults also, if taken in considerable quantity. 

Medicines sometimes become a necessary evil. Avoid their employ- 
ment as much as possible. Second, use them, if at all, in small quan- 
tities, regularly, day by day, not allowing the patient to become consti- 
pated, and then giving a purgative dose, but seeing that a passage from 
the bowels is obtained each day. Third, change the drug or combi- 
nation of drugs at short intervals, so as to prevent the intestinal canal 
from becoming accustomed to any one remedy. Enemata, glycerine 
one tablespoonful in a pint of warm water, injected high up into the 
bowel, will move the bowels ; also suppositories of glycerine or gluten 
will act upon the rectum and lower colon, and produce faecal discharges. 
They are less effective in emptying the upper portion of the bowels or 
colon. They are used only as a substitute for laxatives, or for the pur- 
pose of obtaining a stool when the laxatives have failed to act. 



248 Diseases of the Rectum and Anns. 

We have saline and vegetable laxatives. Among the saline laxa- 
tives must be placed the various mineral waters, too numerous to men- 
tion, which are very useful, as well as fashionable. The natural mineral 
waters are considered to be a little better than the artificial preparations. 
Gn the other hand, a single saline, such as Rochelle, Epsom, or Glauber's 
salt, or citrate magnesia, may be administered by itself. The saline 
should always be given immediately upon getting out of bed in the morn- 
ing, and should be taken in a half pint of water, hot or cold, according 
to the condition of the patient. 

Vegetable Laxatives. — Among the most popular may be mentioned 
extract of cascara sagrada, or the fluid form, or an elixir, given on going 
tombed ; or it may be administered night and morning. Dose to suit the 
age of the person and the severity or chronicity of the case. Com- 
pound licorice powder, a heaping teaspoonful night and morning, works 
well in many cases. 

The following pill : — 

1£: Aloin gr.-J- 

Strychnine gr-sV 

Ext. belladonna 8 r -iV 

Mi see. 

is a most efficient pill given after meals, three times a day, or one night 
and morning may suffice. 

Extract of colocynth, preferably in combination with extract of 
belladonna, is very useful. Preparations of senna, of resina, of podo- 
phyllin, or of rhubarb, are excellent changes, which ought to be often 
made in obstinate and old chronic cases, where medicines have to be 
resorted to. E serine is rather a new remedy, or it has not been much 
used until recently. It is said to work extraordinarily well in chronic 
constipation. It acts simply as a stimulant of the muscular coat of 
the bowels, and is especially valuable in elderly and other people, in 
whom the intestinal muscular fibers are failing in power. By its use 
the amount of laxative required may often be very gradually reduced. 
The ordinary dose is from ^ to F V of a grain, though ¥ V bas been 
administered with impunity. 

Liquid preparations have the advantage over pills, as the dose can 
be readily decreased or graded to suit the case. The following is a 
simple formula: — 

1^: Pulveris sennse gij 

Pulvis yingiberis |j 

Pulveris aloes 5ij 

Spts. frumenti . . 3 j 

Misce. 

Agitate frequently, and, after three days, take at bedtime from 
thirty to sixty drops of the clear liquid. Increase or decrease the dose 
according to the case. This is a very satisfactory laxative, and should 
not be very expensive. Generally it is most desirable to give vegetable 
laxatives at night, as it requires some hours for their action. Vegetable 



Diseases of the Rectum and Anus. 249 

laxatives, such as cascara sagrada, the fluid extract, from a half tea- 
spoonful to a teaspoonful night and morning, or after each meal, act 
well when administered in this way. It is said it is better to give 
eserine in small doses after each meal than it is to give one full dose 
at bedtime. 

Sometimes there is much difficulty encountered in the removal of 
impacted faeces. It is essential in all procedures to avoid, as far as pos- 
sible, the production of irritation ; therefore great gentleness should be 
used, and irritant, drastic cathartics should be avoided. It is better 
to give small doses of calomel, from one-fourth to one-half grain, given 
alternately with Epsom or Glauber's salts, every two hours, until the 
bowels move. Never give over two grains of calomel, with a grain or 
two of soda with each dose of calomel. Do not permit the patient to 
eat anything sour while the calomel is being administered, and thor- 
oughly move off all the impacted faeces before any acid drinks are 
allowed. When the patient feels that the bowels want to move, an injec- 
tion of flaxseed tea, with olive-oil, three tablespoonfuls of the oil in a 
pint of flaxseed tea, should be administered, with the patient in the 
kaee-and-chest position or lying on the left side; and it should be 
retained as long as half an hour if possible ; then, if this does not 
move the bowels, inject warm, thin corn-meal gruel enough to move 
them freely. As soon as the bowels are thoroughly cleansed, use the 
following pill to restore the power of the colon and rectum, thus induc- 
ing a regular action of the bowels : — 

1^: Ferri sulphas exsicc grs.xv 

Quinae sulphas grs.xxxv 

Ext. nuces vom grs.x 

Ext. aloes aq grs.xxxvi 

Ext. tarax q. s. 

M. et fiat pil in capsules no. xxxvi 

Take one pill three times a day after meals. Faradization is 
advantageous in these cases. An old-fashioned "black draught" of 
senna and Epsom salts is more generally useful. One-sixth of a drop 
of croton-oil is sometimes combined with a vegetable drug in obstinate 
cases. 

In some cases the sphincter may have to be dilated, under an anaes- 
thetic, so as to reach the interior of the rectum without any difficulty, 
and break up the mass with your finger, or a scoop, or the handle of an 
old-fashioned spoon. The spasms of the sphincter being thus over- 
come, a great deal can be done in emptying the rectmn. A fountain 
syringe filled with hot soap-water will be excellent to wash out the rec- 
tum. Lastly, inject flaxseed tea and linseed oil, about a tablespoonful 
of the latter to a teacupful of the former. This, if retained, will aid 
the bowel to evacuate after the patient recovers from the anaesthesia, 
or it will soothe the rectum and add to the comfort of the patient. Oil 
and fresh ox-gall may be administered by the rectum, and the patient 
will often get rid of enormous quantities of faeces from their use. 



CHAPTER XII. 
DISEASES OF THE FEMALE BREASTS. 

Sore nipples are sources of great distress, and too often the precur- 
sors of mammary abscess. They are thought doubtless to be caused by 
spme apthous condition of 'the child's mouth ; but they as frequently 
result from some unusual sensibility of the skin of the part, and at times 
from want of care. In first pregnancy mothers should always harden 
their nipples by the daily use of some spirit lotion or cologne and water ; 
and where they are not sufficiently prominent, a breast-glass or gutta- 
percha shield should be worn, as these means tend to prevent this 
troublesome affection. 

Treatment. — When sore nipples occur at the time of suckling, the 
rubber shield may be worn, great care being observed to dry the nipple 
after use. Wash the nipple after use in warm borax water, and never 
leave it in the child's mouth after nursing the child. The application 
of glycerine and tannic acid may be applied to the nipple and the 
breast near the nipple between the times of suckling the child. A solu- 
tion of nitrate of silver, five grains to the ounce of water, applied after 
nursing the child, night and morning, is very useful in healing the 
cracked or fissured nipple. Burnt or dried alum powdered over the 
raw surface of the nipple is also serviceable. The mother must remem- 
ber to wash the breast thoroughly before suckling or nursing the child. 
Castor-oil is a very soothing application, to be applied twice a day. 

ENGOEGEMENT OF THE BREASTS. 

This takes place when from any cause a woman is unable to give 
suck, either from defective disease of the nipple or from the death of 
the child. Under these circumstances the glands are liable to become 
tense and distended, and if left unrelieved for twenty-four or thirty- 
six hours, they will probably inflame. The gland can be relieved by 
the application of the child ; or, if the infant can not draw the breast, 
a very carefully-applied breast-pump may relieve the engorgement, 
and no harm follow. Many women have been relieved by a young 
puppy drawing the breasts. Another ancient (so to speak) method is 
a good plan ; that is, for the mother to draw out the nipple by means 
of the old-fashioned feeding-bottle before giving it to the infant, the 
mother's nipple being put in the central opening, and her mouth draw- 
ing the artificial one. Another method is the application to the nipple 
of the mouth of a wide-necked, empty bottle, that has been heated by 
hot water, the nipple, as the bottle cools, being pressed into the bottle 
(250) 



Diseases of the Female Breasts. 251 

and rendered prominent in a painless way. Immediately put the 
infant to the breast. 

After the engorgement of the breasts has been relieved, pressure 
should be employed, by means of strapping the breasts. This strapping 
is done by means of a woolen bandage, or, better still, a surgeon's 
plaster, applied over the glands, which have been previously smeared 
with the extract of belladonna and glycerine in equal parts. A saline 
or other purge, as flour of sulphur, is of much value, with some tonic 
medicine, as quinine, one or two grains two or three times a day. Two 
or three drams of the sulphate of magnesia is a good saline laxative in 
these conditions. 

In lobulated engorgement of the breasts, gentle rubbing, or friction 
with camphorated oil, is of great value. Warm, moist applications are 
very useful. Keep two or three thicknesses of flannel applied over the 
breasts until well. 

IXFLAMMATIOX OF THE BEEASTS. 

Inflammation may appear as either subcutaneous more or less ex- 
tensive periglandular abscess, a local phlegmonous lobular inflammation, 
or a diffuse abscess throughout the whole gland. It may primarily in- 
volve the connective tissue which extends between the lobules, as well 
as the true secreting structure of the glands. It may likewise occur 
behind the gland. It may be acute or chronic in its nature. It may 
run its course without any breaking up of its tissue or suppuration, or 
be attended with most destructive local results, the extent of destructive 
tendency depending upon the severity of the inflammation and the 
amount of constitutional power of the disease. As a rule, suppuration 
usually takes place. 

Creighton says : "When the mamma, in its state of full expansion 
and perfect functional activity, becomes the subject of interference, the 
result is very commonly a diffuse or nodular inflammation and the 
formation of an abscess. A sudden stoppage of the milk as soon as lac- 
tation has been established is apt to produce inflammation, and the same 
result, or a degree of it, sometimes attends the weaning of a child after 
a long course of suckling. The disturbing cause, whatever it may be, 
acts upon the mamma when its function is at its greatest intensity, and 
the characteristic effect is inflammation and abscess." 

In a general way, inflammation attacks the breast glands when in 
a state of activity, and it is exceptional for the passive organ to be the 
subject of this process. 

Kochler, Bunom, Bryant, and Winckel consider the first two weeks 
as the most common time for mastitis to appear. Cessation of lactation 
seems to increase the frequency of inflammation ; but it is to be remem- 
bered that this cessation may be the result rather than the cause of 
inflammation. Ballard states that abscess in the early months is due 
to the sucking of the child before the gland is filled in the mother's 



252 Diseases of the Female Breasts. 

breast, when there is not sufficient power to secrete milk or to resist the 
inflammatory process when once originated. The affection is more com- 
mon in young primiparse, and the right breast is more frequently affected 
than the left, in ratio of five to three, according to Mr. Bryant's observa- 
tion. In some cases the rapidity of an abscess is very marked, one 
forming within a few days, while in others it is much longer, perhaps 
two months. "Chronic abscesses have often been mistaken for new 
growths, and amputation of the gland performed under this false diag- 
nosis. 

"Abscesses occur in 'the breasts from injury and from cold. 
Abscesses occur in the infant's breasts ; and it is too commonly the con- 
sequence of an ignorant nurse applying pressure to the glands in which 
milk is found, or friction to the glands to rub away the milk. The milk 
appears to be more abundant in the male infant than in the female." — 
Bryant. 

They are also met with in the male subject from other causes. 

Chronic mammitis in the boy or girl is said to be by no means a 
rare affection, the undeveloped gland becoming indurated and painful. 
Such cases rarely suppurate. 

Treatment. — The activity of the treatment of the affection we are 
now considering must be regulated by the acuteness or severity of the 
inflammatory process, and the nature of the constitutional and local 
symptoms to which it may give rise. In all cases of mastitis the con- 
stitutional powers are generally feeble, and the disease is of a destructive 
nature ; hence nothing like lowering measures should be adopted ; but, 
on the contrary, soothing local applications and constitutional tonics 
with sedatives are absolutely demanded. 

In cases occurring during lactation, no other principle of treatment 
than those we have mentioned should be entertained. Under such con- 
ditions soothing fomentations should be applied to the breasts, either 
of warm water or some medicated solution, such as a decoction of 
poppies. What is better is a light linseed poultice, with tincture of 
opium sprinkled over the poultice, and placed over the breast, and a 
piece of oil-silk over the poultice, or a warm flannel, thus keeping up 
the regular heat, by changing the poultice frequently; or lay a hot- 
water bag, filled only partly with hot water, over the flaxseed poultice. 
In the case of young, robust women, where suckling is impossible, 
saline laxatives should be given in large doses every four hours, until 
the bowels are thoroughly cleared out. Often it is necessary to give 
a half grain of calomel every hour, until three doses are administered ; 
then give the saline laxative, — Epsom salts, a tablespoonful in about 
six or eight hours after the last dose of calomel has been given. If 
this does not move the bowels freely, repeat the dose in four hours after 
the last one was given. 

Rest in bed should be insisted upon, as it affords comfort, and, when 
it can be carried out, is of great practical advantage ; but if the patient 
can not rest in the recumbent position, the whole breast must be sup- 



Diseases of the Female Breasts. 253 

ported by a band of flannel or linen sling. During this time tonics, 
such as can be borne, may be indicated, and should be freely given. 
Quinine ranks first as a rule. It may be given in one or two-grain 
doses, two or three times a day. A sedative at night is also very gener- 
ally required. Dover's powders, in ten-grain doses, are the best form. 
After the first purgation no more should be given, except mild saline 
laxatives, such as citrate of magnesia, or a dose of Rochelle salts occa- 
sionally. 

OPENING A MAMMARY ABSCESS. 

There is a great difference of opinion among surgeons about the 
propriety of opening a mammary abscess. Some advocate an early 
opening, and others leave it to nature. The practise some others adopt 
is to leave the parts alone until pointing has taken place, and then 
puncture, making an incision in a line radiating from the nipple. 
Warm fomentations at first, then applications of linseed meal, are the 
best in all stages of the disease. They are very grateful to the patient, 
and should be freely used. When the abscess has discharged, the 
poultice may be laid aside and some antiseptic application employed, 
such as carbolized vaseline, as constant poulticing soddens the integu- 
ment and retards the process of convalescence. 

TREATMENT OF CHRONIC ABSCESS. 

The existence of a chronic abscess having been made out, the treat- 
ment becomes an important question. When the abscess is small, caus- 
ing little or no annoyance, some surgeons recommend letting it alone, 
and, under the influence of tonics and local pressure, by means of strap- 
ping the breasts with surgeon's plaster, the fluid may be absorbed. In 
the majority of cases more active treatments are necessary, and of these 
the evacuation of the pus is the chief point. The best method appears 
to be a free opening at the first operation, the surgeon subsequently 
inserting a strip of oiled lint into the cavity of the abscess for a few 
hours, to prevent the wound from closing. 

SUB-MAMMARY ABSCESS. 

Abscesses occasionally form behind the breast gland, over the 
pectoral muscle ; and when they do the gland or breast is pushed for- 
ward in a way that is characteristic. The abscess, as a rule, points 
below the breast. Such abscesses should be opened in the most depend- 
ent position as soon as any indication of fluctuation can be made out. 
This disease is very slow in its progress. 

CHRONIC INDURATION OF THE GLAND. 

This affection is chiefly found in unmarried women, between the 
ages of thirty-eight and forty, though it occurs in the married, and 
then, as a rule, in the sterile. The gland is morbidly excited. It is 



254 Diseases of the Female Breasts. 

usually associated with some catanienial irregularity or some general 
disturbance, more particularly of the nervous system. 

Symptoms. — The affection is known by excessive sensibility of the 
indurated gland on manipulation, by the nervous excitement the exam- 
ination causes, by the total absence of any local indication of a tumor 
when the fingers are placed flat upon the part, and by the induration 
of the gland, or lobe of the gland, when the organ is raised from the 
pectoral muscle and pinched. 

Treatment. — The treatment consists in correcting what is wrong 
in the general constitution of the patient, by the means of iron, tonics, 
and alteratives. Gude's pepto-mangan of iron, or Fellow's syrup- 
hypophosphites and compound syrup of sarsaparilla, with a little iodide 
of potash added to it, may be taken three times a day. A belladonna 
plaster affords relief with or without pressure. With the anode of the 
galvanic current applied to each nodule or indurated lobe of the breast, 
and the cathode or negative pole applied over the ovary on the corre- 
sponding side, give from fifty to eighty milliamperes, for at least ten 
to fifteen minutes where there is only one enlarged gland ; but if multi- 
ple, give from seven to ten minutes over each enlargement. Treat 
every other day, until the indurations get thoroughly softened up, 
when they gradually disappear. 

The writer has had many such cases, and has always found that 
the galvanic current yielded comfort to the patient and a retrogression 
of the growth, in many cases has cured, and in all cases greatly bene- 
fited. Large breasts should be suspended, and all should be covered 
with cotton wool, to prevent risk of injury or taking cold. I have found 
young girls with irritable breasts, similar to those just described. In 
every instance the young girl was troubled with some kind of pelvic 
trouble, especially lateroversion of the uterus, with considerable thick- 
ening of the broad ligament ; and in eight cases there was flexion of the 
neck of the uterus. In these cases I placed the cathode in the cervix 
as far as possible, and the anode over the breast, giving from ten to 
fifteen milliamperes ; seance seven minutes. I first treated the patient 
over the ovarian region, by placing the anode over the lumbar region 
corresponding to the ovary to be treated, and the cathode over the 
ovary, giving from fifty to eighty milliamperes; seance not less than 
ten minutes. Next place the positive flat electrode over the indurated 
breast, and the negative either over the ovary or over the fundus of the 
uterus externally, for at least fifteen minutes ; then, last move, place the 
negative pole of aluminum wire (insulated with rubber tubing nearly 
to the end, which is wrapped with a bit of absorbent cotton dipped 
in boracic solution) in the cervix, the flat electrode remaining over the 
breast, giving twenty to thirty milliamperes ; seance, ten minutes. 
Give three treatments a week till relieved. 





Plate d. — Hypertrophy of the Breasts. 



Diseases of the Female Breasts. 255 

FUNCTIONAL DISTURBANCES AT THE TIME OF THE CHANCE IN WOMEN. 

"The circumstances of the functional disturbances are never 
exactly the same in any two cases. When a tumor forms in a breast 
within the period when the function may be awakened to its full and 
healthy vigor, that is, during the time of its structural and functional 
maturity, a resolution of the disease or the dispersion of the disease 
product may be looked for ; but when it appears at or near the change, 
or climacteric period of years, when the gland is suffering an effacement 
of its secreting mechanism, and a withdrawal of its secretory force, no 
such result can be expected, and it is at this period that the greater 
number of intractable tumors occur." 

"It is the climacteric effacement of the breast that gives a peculiar 
character to the disease in women, and there are well-marked structural 
differences in the tumors according as they appear before or after that- 
period. Those that develop after the change of life, or climacteric 
years, are perhaps the most common, and they have been the real source 
of ambiguity in the pathology of the organ." 

Dr. Creighton's investigation shows that the adenomata, sarcoma, 
myxoma, and carcinomata have their types in a series of changes, pro- 
gressive in form, which the gland undergoes in its physiological evolu- 
tion. The feebler the intensity of the function, the more cancerous the 
disease; the higher or more advanced the evolution from the resting 
state, the more benign the tumor. 

HYPERTROPHY OF THE BREASTS. 

This means an excessive growth. 

Treatment. — The galvanic current is the proper treatment. Place 
the anode, flat electrode, over the breast, and the cathode over the spine 
or over the ovary. This will, if persevered in, check the growth. Keep 
the breasts suspended. All malignant growths should be operated upon, 
which is the only hope for relief. 



CHAPTER XIII. 
DIAGNOSIS OF CHILDREN'S DISEASES. 

(Quoted largely from J. Finlayson, M. D.) 

Diagnosis. — We usually begiu by asking our adult patients how 
they feel, or where the pain is, if any be present. But our little patients 
may be too young to speak, or, if they do speak, the pains and discom- 
fort may be referred to in a misleading manner ; thus, it is common for 
a child with a pain originating in the chest to refer it to the stomach 
or the belly, and this not merely in words, but actually by direct signs. 
All the information we are in the habit of getting from the child's 
descriptions of his or her discomforts may thus utterly fail us. The 
distress may be as great or even greater than that of a grown person ; 
but the "infant crying in the night," however definite, obscure, complex, 
or varied the nature of its misery may be, has "no language but a cry." 

The methods for examining any sick person must be determined 
by the actual condition at the time, whatever plan may be in the mind 
of the physician. In the case of a sick child this is preeminently true. 
Urgent symptoms, like fits of any kind, or obvious features, like the 
appearance of an eruption, demand, of course, direct attention, without 
much preliminary inquiry. In ordinary cases it is well, as a rule, to 
hear from those in immediate charge of the child a full and connected 
account of the illness and its supposed cause, taking special notes of 
the exact dates on which the various events occurred, as this precision 
as to time often leads the narrator to correct, or modify, or expand the 
original statement. This preliminary statement is best obtained in the 
sick-room. The physician can then sit down without attracting the 
child's attention to the visit's having any direct reference to her ; or the 
child may, at times, go to sleep during the narrative, and so afford a 
chance for seeing the effect of this state. Unless the child is very 
young, it is often best to get all this account in another room, out of its 
hearing; but, in any case, it is important that the examination should 
not be begun until the physician has a pretty clear view of what points 
may come up for investigation. 

It is usually desirable to ascertain by definite and categorical 
questions whether the illness, as now existing, appeared to come on in 
the midst of perfect health, and if not, to ascertain with precision up 
to what time the child might be regarded as perfectly healthy. Unless 
this is put to the mother as a definite question, much confusion is liable 
to creep into the narrative. In very young children it is usually best 
to hear the whole medical history of the infant, with dates of weaning, 
teething, walking, etc., connecting the past history of the child with 
(256) 



Diagnosis of Children's Diseases. 257 

his or her present illness. Any previous illness of the child should 
also be fully considered, as this often has a direct bearing on the case, 
even when the previous illness may seem of an accidental character, 
such as measles or whooping-cough ; and this is all the more important 
when the illness investigated is chronic, and perhaps of an obscure or 
an indefinite character. To obtain a connected account of the child's 
illness is a matter of no small difficulty. The greatest forbearance and 
patience must be shown to women worn out in watching the young. 
Let them tell their story in their own way, and supplementary infor- 
mation can be gained by questioning. When a woman of good sense 
in attendance on a child alleges that it is ill, or that it is worse, the 
chances are that she is right, even though the proofs she may adduce 
may seem trivial or erroneous. Some women exaggerate in their inter- 
pretation and theoretical ideas, and so are apt to be wrong as to the 
nerves, etc., while others have the power of arguing clearly enough 
according to their knowledge of the case. All their statements should 
be weighed seriously as to the actual facts of the illness, and especially 
as to the general condition. 

For the personal examination of the child there should be the 
greatest flexibility of plan, and a ready promptness in taking advantage 
of every chance which may arise, and in deciding at once which points 
are of the greatest immediate importance in the case. Thus, if the 
child is asleep, the pulse may be taken, respiration counted, the gen- 
eral character of the breathing observed, and the color of the face 
noticed. If the case seems to be one of abdominal disease, this sleep- 
ing state affords an opportunity for examining the belly, slipping the 
warm hand under the clothes of the sleeping child, and ascertaining 
the condition of the walls and of the internal organs, before crying, or 
fright, or pain may render the parts so tense as to baffle the observer. 
At times, by sitting down and taking the temperature in the axilla, 
holding the arm to the side, or getting the mother or nurse to do so, we 
may allow time for the agitation and fright at the sight of a stranger 
to subside. 

It is often the case, however, that the greatest patience and tact 
seem alike thrown away, and the examination must remain very incom- 
plete, or perhaps special parts of it, if of extreme importance, may have 
to be carried through by main force. Usually this depends less on the 
nature of the illness than on the habitually bad moral training the child 
has received from the parents ; or it may be because the medical exam- 
ination or treatment in this or in some previous illness has been of a 
harsh nature. The examination of the throat may have to be done by 
main force, and for this reason it is usually left to the last. Some 
young children will give every facility, and, by getting them to open 
their mouth widely, and draw a deep breath, we can see the fauces well 
enough; or we may require to aid the view by a gentle depression of 
the tongue with the tip of the finger or the end of a spoon. When such 
methods are not available, or fail to suffice, the best way is to make 



258 Diagnosis of Children s Diseases. 

preparation for securing proper light from windows or lamps or candles, 
and have good assistance for holding the child firmly during the exam- 
ination, and for controlling the arms, which are often best kept out of 
the way by a blanket or a sheet held tightly around the front of the chest 
so as to include them. When all is ready, the mouth may have to be 
opened by main force, and even the nostrils held in separating the lips 
and teeth, and then with the handle of a spoon, spatula, or a tongue- 
depressor slipped quickly between the teeth and a little more than mid- 
way of the tongue, press the tongue down gently, and in the meantime 
let go of the nose, so the child can breathe easily, while the tongue is 
neld down and the head turned so that both sides of the fauces can be 
seen in a good light. We are often aided by the gasping breathing of 
the child, or even by the efforts at vomiting. If proper arrangements 
for the examination have not been made before beginning, you may have 
it all to do over again. 

Young children are usually examined best on their mother's knee ; 
if in bed, they can be lifted out with one of their warm blankets around 
them; this change often helps to pacify them if fretful. The child 
must be kept covered with a soft shawl or blanket, warmed to prevent 
the child from getting cold while being examined. Small portions of 
the body are exposed at the time of the examination; then the shawl 
may be tucked around the loins while the back of the chest is being 
examined, or the shoulders, or the abdomen, as the case may be. If 
in a warm room a small portion of the body is exposed at a time, 
injurious results seldom follow. But if a large surface is exposed at 
once, it is quite a different matter, and, with the lower part of the back 
uncovered, the child is apt to take cold. If the child should be moist 
from sweating, or from poultices, the body should be dried with a warm, 
soft towel before exposing it for examination. 

With some tact on the part of the nurse, when the child is sitting 
on her knee, its back may often be pretty well examined before the child 
realizes that anything except rearranging the clothes is being attempted, 
for the observer keeps literally, as well as figuratively, in the back- 
ground, and some one may perhaps divert the child's attention in front 
by showing some bright object, as a lighted taper, trying, of course, to 
avoid, as far as possible, any distracting sounds in carrying out this 
diversion. In very young children, and even in some others, the back 
of the chest can often be examined by laying the child on its abdomen 
on the nurse's knees, and then uncovering the back. The child is often 
pacified, for a time, by this change of position, to which, of course, he is 
accustomed during the process of dressing and renewing the napkins. 
A similar benefit is often obtained by getting the nurse to hold the 
young child close to her breast, with the face of the infant toward either 
shoulder as if looking over it ; and when the child's vision is thus directed 
away from the physician, the back may be in part uncovered for the 
purpose of examination. When the child is laid flat, the front of the 
chest may be examined by percussion-sound, or by the "series of strokes" 



Diagnosis of Children's Diseases. 259 

obtained in varying stages of inspiration and expiration, as the breath- 
ing is often so rapid that no other basis of comparison can be obtained. 
Auscultation of the front of the chest is usually best accomplished by 
means of a stethoscope, although the direct method can often be prac- 
tised with advantage in this situation; and sometimes we are glad to 
try both methods if we fail at first. 

The examination of the abdomen may often be taken with advan- 
tage before proceeding to the front of the chest. The relative impor- 
tance of the two parts of the examination, as judged from the history 
of the illness, must guide us. If the child is lying quietly, we may 
be able to palpate the abdomen and determine the position of the organ, 
or the presence of glandular or other swellings, before attempting the 
examination of the chest; for this, of course, however carefully per- 
formed, may lead to a fit of crying. 

The exploration of the abdomen is often most important, but not 
seldom the difficulties are extreme. ISTo chance should be missed of 
examining it during a quiet period, perhaps while the child is asleep, 
perhaps before risking an upset from the examination of the chest. 
On the other hand, we may with equal propriety postpone the examina- 
tion of the abdomen to the last if the child is cross, in hope of a better 
chance. Too often in young children we are confronted with the diffi- 
culty of extreme tension of the abdominal walls, with resistance and 
screaming and kicking ; and in our attempts to make examination, pal- 
pation and percussion are equally useless. Sometimes, by keeping the 
hand lightly applied under the clothes until the child is settled, we may 
be able, without arousing his fears, to feel the state of matters as regards 
laxity, tenderness, or tumors. 

In palpation we must see that the hand is warm, and that it is 
applied, in the first instance, gently and lightly, carefully avoiding any 
sudden jerks with the fingers, but feel with the whole hand, so as to 
avoid exciting the muscles to resistance. The presence or absence of 
tension of the walls is important. We often find tense inflammatory 
affection of the bowels and of the peritoneum, even apart from effusions ; 
and if we can press down a lax abdominal wall without eliciting signs 
of pain, we may almost presume that there is no peritonitis. The 
mere inability to do this counts for little, unless circumstances favor 
the examination, as the least fright may render the abdominal muscles 
extremely tense, and pressure then readily causes pain and further 
resistance. 

The next point is to determine the position of the organs and pres- 
ence of any solid tumor. The liver can easily be felt, but it may, 
erroneously, be supposed to be enlarged, when but little changed in size. 
It must be remembered that the liver is relatively large in young chil- 
dren, and that it is also relatively prominent in them below the ribs; 
moreover, in rickets and other distortions of the chest, the liver is dis- 
placed §o as to simulate a great enlargement. Indeed, the whole belly 
is often very prominent and distended in rickets. In ricketv children 



260 Diagnosis of Children s Diseases. 

the spleen may also be readily found at times, partly from enlargement 
and partly from displacement. The spleen may be found enlarged in 
scrofulous children, with, it may be, albuminuria or other signs of 
amyloid disease. Occasionally the spleen is enlarged from ague, which 
must be inquired for. Concurrent disease of the liver may suggest the 
cause of splenic enlargement. Emboli are said to increase the size of a 
child's spleen. 

Any pain or tenderness felt during the manipulations of the 
abdominal region, etc., should be noted. It is said there is not, as a 
rule, any tenderness on pressure in a large number of cases of tubercular 
peritonitis in children. 

The prominent belly contrasting strongly with the wasted state 
of the chest and of the thighs, is a familiar appearance in tubercular 
disease of the abdominal organs, even in cases where there may be 
little or no fluid present. 

Often great importance is to be attached to finding little tumors 
or lumps in the abdomen in cases of suspected tubercular peritonitis 
and tubes mesenterica. The uniform distention of the abdomen from 
fluid in the peritoneum often contrasts with more localized swellings 
from tumors there. The discrimination must be made by percussion 
and palpation, as in the case of adults. Fluid in the abdomen is often 
due to tubercular disease, although it may be due to dropsy from dis- 
ease of the heart and the kidneys, but in such cases we have more or 
less dropsy elsewhere. A suddenly-developed dropsy localized in the 
abdomen may depend, as in the adult, on disease of the liver, perhaps, 
it is said, due to thrombosis of the portal veins. In such cases we look 
for an enlarged spleen, and we inquire for haemorrhages from the 
stomach or the bowels. We also examine for jaundice or other signs 
of hepatic disorder. In bad peritoneal dropsy, from any cause, we may 
see hernial protrusions with fluid in them communicating with general 
abdominal effusions. 

The chest is, of course, best surveyed when both chest and abdomen 
are completely uncovered ; but the actual state of the child must deter- 
mine whether it is wise to have it so. "The appearance of marked 
wasting, with great distinction of the ribs ; the existence of any of the 
forms of 'pigeon-breast,' and prominence of the sternum, and an accen- 
tuated transverse groove above the liver; the presence of the so-called 
'beading of the ribs,' consisting in visible and palpable swellings at the 
end of the ribs where they join the cartilages; various bad conforma- 
tions of the chest, whether with depressions of the lower end of the 
sternum or with unilateral distortions interfering with the symmetry of 
the chest ; bulging forward of the sternum, with a tendency to the 
circular form of the chest, indicative of emphysema in older children, 
as in adults — all these various structural peculiarities can often be 
sufficiently appreciated at a glance." 

The awful dyspnoea in croupy attacks, with powerful action of the 
muscles of the neck, and sudden elevation of the upper part of the 






Diagnosis of Children's Diseases. 261 

sternum and ribs, almost in a mass, coupled with recesses of the ribs 
in the lateral region, and sucking in of the lower part of the flexible 
sternum, tells at once of the urgent need for air experienced by the 
child, and of the mechanical interference with its entry into the lungs. 
An excited action of the accessory muscles of respiration, with panting 
and heaving of the chest, but without the recession movement just 
described, characterizes attacks of spasmodic action in the child as in 
the adult ; for. although not very common under the age of twelve or 
fifteen years, genuine spasmodic asthma in children is not so very 
infrequent as it is often supposed. Marked unilateral respiration, 
with one side heaving rapidly and the other motionless, is very sug- 
gestive of a large pleuritic effusion, and this is rendered almost certain 
if we detect, on getting a fair view of the chest, that the motionless side 
is larger and fuller than the other, with obliteration of the inter- 
costal spaces. Some rearrangement of the position of the child may 
be required to ascertain this, as the decubitus is invariably on the 
affected side. Marked unilateral retraction and immobility at once 
suggest in a child the results of an old pleurisy or an empyema, 
although, of course, it may depend on long-standing pulmonary excava- 
tion or on the contraction of a fibroid phthisis. Moderate flattening 
and contraction under the clavicle, or impaired movements there; ful- 
ness over the pericardial area from effusion ; general bulging of the 
tissues of the chest and neck, with crackling on touching it, due to sub- 
cutaneous emphysema, — all of these require detailed examination, and 
can not be recognized the moment the chest is seen, as in many of the 
conditions already mentioned. 

STATE OF GENERAL DEVELOPMENT ; WEIGHT, DENTITION, WALKING. 

The child's clothes must be removed to afford an opportunity of 
judging of the general development. The large head, prominent 
belly, and distorted chest may at once fix our minds on a case of rickets, 
even apart from any deformity of the limbs ; but usually, even in chil- 
dren who have never walked, we may see evidences of rickets in the 
great prominence of the curvature of the clavicles, appearing as if they 
had undergone repairs from fracture, and in the curved arm and fore- 
arm, resulting from resting the weight of the body on the upper limbs 
while sitting up in bed; enlarged wrists and ankles, and open or soft 
fontanels, come to our aid as confirmation. A wasting appearance of 
the chest and limbs, contrasting with a great prominence of the 
abdomen, with or without the presence of any fluid, has already been 
referred to as strongly suggestive of tubercular disease in the peri- 
toneum or mesenteric glands, constituting an affection of special 
importance in childhood, as it is relatively frequent at this period of 
life. It is best spoken of as ''abdominal phthisis," owing to the fre- 
quently uncertain and mixed character of the pathological conditions 
actually present. 



262 



Diagnosis of Children's Diseases. 



Mean Height and Weight of 10,904 Girls in the United States 

of America (Including 3,681 American, 3,623 Irish, 

585 German, and 1,397 Mixed English, Irish, and 

American Parentage). Dr. Bowditch. 



Abstract from Roberts' "Anthropometry." 





HEIGHT, WITHOUT 


WEIGHT, INCLUDING 


AGE LAST BIRTHDAY 








SHOES 


CLOTHES 


5 years 


41.0 inches 


40 lbs. 


6 years 


43.5 inches 


44 lbs. 


7 years 


45.5 inches 


48 lbs. 


8 years 


47.5 inches 


52 lbs. 


9 years 


49.5 inches 


56 lbs. 


10 years 


51.5 inches 


60 lbs. 


11 years 


53.5 inches 


66 lbs. 


12 years 


56.0 inches 


76 lbs. 


13 years 


58.0 inches 


88 lbs. 


14 years 


60.0 inches 


96 lbs. 


15 years 


61.0 inches 


104 lbs. 


16 years 


62.0 inches 


110 lbs. 


17 years 


62.0 inches 


112 lbs. 


18 years 


62.0 inches 


114 lbs. 



Of course, in consumptive diseases, whether in the chest or abdomen, 
we may have a wasting which involves the belly also in the general 
atrophy, the whole child presenting a uniformly shrunken appearance. 
But in quite a part of the affections of this kind, the whole body also 
may be pretty equally atrophied, as is seen in a multitude of cases of 
wasting disease arising from malnutrition due to improper feeding or 
diarrhea, even apart from any consumptive or tuberculous tendencies. 
The patient's face is small, and assumes the appearance in many ways 
of that of an old person. A good place to judge of the wasting in a 
child is in the upper part of the thigh in the region of the great adductor 
muscles. We may with advantage test the tone of the tissues by pinch- 
ing up the skin here, the raised fold thus made taking a long time to 
efface itself in case of wasting and debility ; even the skin pinched up 
on the abdomen may linger as a visible fold to a striking extent. 

Along with signs of general wasting, we have often- badly-formed 
nails, or we may find the curving and clubbing familiar to us in 
phthisical adults. Frequently along the spine, and extending toward 
the scapula, we see long soft hairs in weakly children, but this sign is 
sometimes found in those who are fairly strong. 

A most important point in the estimation of the development and 
actual condition of children consists in weighing them. 



Diagnosis of Children s Diseases. 



263 



Mean Height and Weight of Boys and Men between 4 and 
50 Years, English Artisan Class (13,931 Observations). 



Abstract from Roberts' "Anthropometry." 







WETGHT, INCLUDING 




HEIGHT, WITHOUT 




AGE LAST BIRTHDAY 


SHOES 


CLOTHES (7 AND 
10 LBS). 


4 years 


38.50 inches 


44 lbs. 


5 years 


41.00 inches 


50 lbs. 


6 years 


43.00 inches 


54 lbs. 


7 years 


45.00 inches 


57 lbs. 


8 years 


47.00 inches 


59 lbs. 


9 years 


49.00 inches 


62 lbs. 


10 years 


50.50 inches 


66 lbs. 


11 years 


51.50 inches 


70 lbs. 


12 years 


53.50 inches 


74 lbs. 


13 years 


55.50 inches 


78 lbs. 


14 years 


58.00 inches 


84 lbs. 


15 years 


60.50 inches 


94 lbs. 


16 years 


63.00 inches 


106 lbs. 


17 years 


64.00 inches 


116 lbs. 


18 years 


65.50 inches 


122 lbs. 


19 years 


66.00 inches 


128 lbs. 


20 years 


66.25 inches 


132 lbs. 


21 years 






22 years 


66.50 inches 


136 lbs. 


23-30 years 


66.50 inches 


138 lbs. 


23-50 years 


66.50 inches 


140 lbs. 



It must be remembered that the normal weight varies relatively for 
the sexes at different periods of life ; that in both sexes it varies, of course, 
with the height ; and that with the same sex and the same height, it will 
vary with the age of the child. The social position of children weighed 
for the purpose of ascertaining averages likewise has a bearing, show- 
ing a greater weight for the more favored classes of society. In the 
case of very young children, the influence of nourishment by breast 
milk determines for the most favored class in this respect an increased 
growth and weight in the early part of life ; and it can even be- traced 
as exerting an influence for some years after birth. 

This difference as to children nursed at the breast and those 
brought up artificially, applies chiefly, if not exclusively, to the poorer 
grades of the community ; at least the evidence, so far as statistical data 
is concerned, applies to this class only, as the other scarcely comes 
within the chance of such observations being made on a large scale. 

But whatever difficulties beset the estimate of a child's weight as 



264 Diagnosis of Children s Diseases. 

compared with any absolute standard, the relative weight of the child 
from time to time is a more definite matter. The weight of a 
child is so small that great care is required in regard to the estimate of 
the clothing. The best way in routine practise seems to be to deter- 
mine the weight of the clothes the child wears while indoors, as this 
leaves the variation from time to time but trifling, although heavier 
underclothing and heavier shoes make a little difference. 

A general falling off in nutrition and weight shows that the opinion 
of careful mothers and nurses is valuable, particularly in young chil- 
dren, even when the weight might show but little change, as the soft- 
ness of the muscles, or, on the other hand, their increasing firmness, 
indicates with considerable certainty the tendency of the case in either 
direction. The important bearing of a gradual falling off for weeks 
or months before the onset of dubious cerebral symptoms, is well known 
in the diagnosis of tubercular meningitis, although in not a few cases 
this dreadful disease may seem to surprise the child before any falling 
off had occurred. Likewise, in other obscure affections of a tubercular 
or scrofulous nature, whether in the lungs, bronchial glands, abdomen, 
or brain, this preliminary deterioration before pronounced symptoms 
had appeared, often constitutes a point of capital importance in the 
diagnosis. 

Particulars as to the order and date of the eruption of the milk- 
teeth will be given in another chapter, so far as these can be reduced to 
a rule. 

The date of walking varies much in perfectly healthy children. 
Any precocity in this respect is in no way desirable, and no anxiety 
should be expressed with regard to it if the child is otherwise quite 
strong and healthy, unless the period goes beyond the fourteenth month, 
although children in good condition usually walk a month or two 
earlier. When, however, we find a child unable to walk at eighteen 
months, the chance of delay being due to rickets is very great, if there 
are no obvious localized defects in the limbs from paralysis, joint- 
mischief, etc. Occasionally the inability to walk depends on a gen- 
eral deficiency of the development of the whole nervous system, 
including a mental defect, to which even when very notable the mother 
is apt to be singularly or perhaps wilfully blind, enlarging, it may be, 
on the remarkable acuteness of her offspring. 

As in the case of dentition, the child's progress in standing and 
walking is often arrested, even after a fair start has been made, by the 
supervention of rickets. "The child is then said 'to have been taken off 
his feet/ " a report which must always suggest the idea of rickets to 
the physician. Of course any acute illness may operate in the same 
way, so that after recovery from measles, a bad bronchitis, or a diarrhea, 
for example, the child may be found to have lost the power of walking, 
only to be regained slowly, so that he may appear to be several months 
behind others of his own age in this respect. 

In cases of inability to walk, we must ascertain by a local exam- 



Diagnosis of Children s Diseases. 265 

ination whether it is due to pain, or dislocation, or any mechanical 
defect interfering with the process. We also examine for atrophy, 
coldness, spasms, and other signs of paralysis in the limbs, ascertaining 
if the child when sitting or lying can move the legs freely. We must 
also examine the back for curvature and other deformities. We like- 
wise search for rickets, or any sign of rickets, or for indications of men- 
tal defects. The case is made clearer if we ascertain whether the child 
has ever walked. 

Precocious development of the sexual organs, or signs of premature 
puberty, are occasionally seen in children of both sexes. When such 
are noticed, we must inquire for any unnatural excitation of the parts 
by the patient or the nurse, or for any evidence of masturbation, which, 
of course, at that age may assume very unusual forms. In young girls 
the premature signs of puberty may depend on some ovarian tumor. 

EXAMINATION OF THE HEAD. 

The development of the child as regards the bony system has been 
alluded to in connection with the distortions of rickets. The size of 
the head varies enormously, and it is not possible to give absolute 
measurements of any great diagnostic value. The size of the head 
depends, of course, very much on the parentage of the child, but it is 
often too large, and sometimes unduly small in disease. 

In rickets the head looks large and the face small. The top of the 
head is usually rather flat, and sometimes gives the idea of a square 
shape. The fontanels are often much wider than usual for the age, 
and may indeed remain unclosed, or covered only by a soft membrane 
for a year or two after they should be closed. Whenever such condi- 
tions are found in the skull we search for other signs of rickets ; in the 
chest for the characteristics of distortion and the so-called "beading" of 
the ribs ; for curves of the bones of both upper and lower extremities ; 
for the actual state of dentition and the history of the same ; the date 
of walking, or going over walking ; and also for tenderness in the bones 
on handling the child. All these particulars come in to help the 
diagnosis. Rickets has such wide-reaching effects, and has, in partic- 
ular, so important an influence on nervous disorders, that the large 
head may readily lead the inexperienced to ascribe laryngeal spasms 
and general convulsions to some grave disease of the brain, while really 
the case is essentially due to rickets, and perhaps readily curable. 

In examining the skull we may find thickened masses or bosses 
around the fontanels especially, or, on the other hand, thinned por- 
tions of bone, soft or almost approaching to the character of holes 
(cranio-tabes). Both conditions have been described by Parrott as 
occurring in rickets, but as he considers this disease a manifestation 
of syphilis, we require to remember this in connection with the detection 
of similar conditions in congenital syphilis. 

The enlarged head of hydrocephalus usually differs from that of 



266 Diagnosis of Children s Diseases. 

rickets so clearly that mistakes do not often arise after a careful exam- 
ination. The upper part of the head is not flat, but often arched or 
vaulted. The fontanel is not merely wide or unclosed, but often prom- 
inent and tense. The sutures issuing from it are frequently wide, with 
a protrusion between the edges of the bone. The face looks small in 
comparison with the head, and there is a peculiar downward look of 
the eyeballs, with, from the same cause, an unduly large part of the 
white sclerotic visible in the upper segments. The enlargement some- 
times remains as a permanent record of the occurrence of hydrocephalus 
in the past, the illness having run its course, and the sutures and fonta- 
nels being all firmly closed. In such cases the intellect may be defect- 
ive, presenting the form of idiocy called macrocephalic ; but enlarge- 
ment of the head in this way by no means involves mental deficiency 
as a necessary consequence. 

Smallness of the head is no less serious a sign than enlargement, 
and when extreme, it is often associated with idiocy (the "microcepha- 
lic" form of some writers). Moderate degrees of smallness must not 
be judged of rashly; for, if the development and shape are otherwise 
good, this may result from family peculiarities of little import. 

Occasionally unilateral alterations in the skull are detected as 
connected with obvious or obscure disease in the central nervous sys- 
tem; while unilateral atrophy, or more rarely unilateral hypertrophy, 
may lead to a want of symmetry, dating, it may be, from birth. 
Another form of want of development of the side of the head and 
face arises in connection with long-standing wry-neck in early life, 
and a slighter form has been ascribed to injurious modes of carrying 
the infant, so as to hinder free movements in all directions. 

The occurrence of the "blood tumor," called cephalhematoma, 
appearing in the scalp of the infant soon after birth, can easily be 
distinguished from the much more serious disorder due to defect in 
the bones of the skull, with protrusion of the brain substance or mem- 
branes, to which the name encephalcocele is applied. We will speak 
of these occurrences later on in this work. 

EXAMINATION OF THE NECK. 

Examination of the spine of children reveals, at times, the two 
well-known forms of curvature with which we are familiar in the adult. 
Acute or angular curvature, described by Pott, occurs indeed with 
special frequency in early life, and its appearance is so characteristic 
as to require little notice here. 

Lateral curvature is, of course, much less common in children 
than in girls at or beyond the age of puberty. But a typical lateral 
curvature may occur even in young babies ; and in such cases we must 
see whether there is an error in habitually carrying the child so as to 
look in one direction only. Very often the lateral curvatures in chil- 
dren are merely secondary results of serious antecedent disorders. A 



Diagnosis of Children s Diseases. 267 

pleurisy followed by retraction of the side, an infantile paralysis, 
grave nip- joint disease, fractures or dislocations in the leg or thigh, 
and indeed anything which shortens one of the lower limbs as com- 
pared with the other, may give rise to lateral curvature of the spine. 

A very common curvature found in young children may mislead 
the beginner by suggesting the presence of caries with Pott's curva- 
ture, when all that exists is simply softness of the bones and muscu- 
lar weakness, such as occurs so frequently in rickets. In these cases 
the back in the lower dorsal and lumbar regions is found to bulge or 
curve backward when the child is made to sit. There is no true 
angular projection, and on taking the weight off the spine by the 
recumbent posture, the curvature disappears. 

An opposite curvature of the lower part of the column, with a 
hollow instead of a projection, gives the spine a "saddle-back" appear- 
ance in this situation. There is a projecting backward of the upper 
part of the spine about the scapula?, and the name "lordosis" has been 
applied to this variety. The deformity is due to paralysis or weak- 
ness of the muscles of the back, and it acquires special significance in 
the diseases of childhood from this "saddle-back" constituting one of 
the most striking features of the pseudo-hypertrophic muscular paral- 
ysis, an affection which we may say is limited to children. 

The peculiar fixity of the head and neck found in occipito- 
atlantoid diseases needs only to be noticed in a word. It occurs with 
relative frequency in childhood. 

The congenital malformation termed spina bifida requires also 
to be mentioned here. Its presence may account for paralysis and 
convulsions in infancy. The gravity of the condition turns in part on 
the level at which tumors exist in the spine, and in part on the nature 
of the contents. 

TEMPERATURE THERMOMETER. 

The introduction of the thermometer into regular clinical work 
has bfcen of signal service, and especially in dealing with children. A 
child with a measly or a scarlet rash may be found to have, on some 
rough observation, a temperature of 102 degrees Fahrenheit. This 
may be enough for the purpose of diagnosis, showing that with the 
rash there is a distinct degree of fever ; and if the child is not very 
ill, it may really matter but little whether the temperature is 102 
degrees Fahrenheit, or whether, if properly taken, it might come out 
103 degrees Fahrenheit or 103V2 degrees Fahrenheit. Of course a 
very great elevation (106 degrees or 107 degrees Fahrenheit) might 
mean something very different ; but in such a case the obvious state of 
the child would likewise be different. 

Formerly this was determined, in part, by the hand applied to 
the child's skin, say over the abdomen, and in part by the counting of 
the pulse. The hand applied to the skin is considered confessedly a 



268 > Diagnosis of Children's Diseases. 

rough method; but when the sense of increased heat is very notable, 
one of experience may get considerable assistance from it. 

But in dealing with instruments of precision, such as good ther- 
mometers, we are exposed to* new fallacies if we do not use them 
properly. 

It is when, perhaps with a low surface temperature, there is a 
very distinct increase of the internal heat, that errors from faulty 
observation become positively misleading, when, for example, we 
may be dealing with a case of enteric fever toward the end of the first 
week, and the thermometer, badly applied, shows a maximum of only 
^100 degrees Fahrenheit instead of 102 degrees Fahrenheit. We 
might here almost infer that enteric fever was excluded by such obser- 
vations, if we trusted to the "instrument of precision. " Or the hectic 
fever of obscure phthisis may be present, but missed by a faulty use 
of the instrument ; and so we might be led, if trusting to the record, to 
set aside the diagnosis of phthisis as unlikely, owing to the supposed 
absence of the fever which we had really failed to discover. Such mis- 
takes are constantly being made, and the educational effect on those who 
make them is toward carelessness, inaccuracy, and confusion. The 
temperature should be taken in the rectum as well as in the axilla. 

A child's axilla is often a very small affair, and especially when 
wasted there is scant covering even for the bulb of a thermometer. 
The instrument readily slips out behind, or falls down, or the arm 
ceases to be applied. To obtain correctness in this, we must see that 
the axilla is closed ; and in young children this means that the observer 
must hold the arm to the side himself. Keep the axilla closed to the 
child's armpit, and push all clothing back from the thermometer, and 
bring the child's arm down over the thermometer, and hold the arm for 
five minutes close over its body until we feel sure that the maximum 
is reached. At times the maximum is reached in one minute, and by 
waiting four minutes longer we have the security of this being the 
maximum. 

In scarlet fever it is very likely we get a rapidly-attained max- 
imum in the axilla, particularly if the arm happens, as it should be, 
to be close to the side, as by the child's lying on it ; but if the arm 
has been moved from the side, or tossed about so as to take up colder 
air into it frequently, if the child is wasted to a skin and bone," if 
with the feverishness there is a tendency to collapse, then we have 
to wait until the influence of the cooling air on the skin is neutralized 
by the increased cutaneous circulation, favored by the apposition of 
the arms to the side. In this way, a long time may be required for 
taking the temperature. Temperature observations can be taken in 
the rectum rapidly, and with great precision, in from three to four 
minutes. The child is placed on the left side, in bed or on the 
mother's knees ; oil the bulb and introduce it into the bowel for a couple 
of inches, keeping the buttocks closed while taking it, and carefully 
covered to avoid undue exposure. The observer should hold the there 



Diagnosis of Children s Diseases. 269 

mometer and place the other hand on the pelvis, to guard against sud- 
den movements displacing the instrument. Often, in from one to 
three minutes the maximum is reached. The rectum, of course, must 
be clear of faeces, to obtain correct temperature. It must be remem- 
bered that in children there is a daily curve of temperature, and that 
to be even roughly comparable, the hours of observation, from day to 
day, must be approximately similar. In serious cases, or in connec- 
tion with therapeutic measures, we may wish to know how far the 
high temperature is continuous, or to what extent remissions occur 
from hour to hour. Observations of the temperature should be made 
every two hours, to the form of the curve, or rise and fall of tem- 
perature. 

The temperature in healthy children can not be correctly spoken 
of as either higher or lower than in adults. It is in a sense both. 
The daily range is greater, amounting to about 2 degress Fahrenheit 
or even 3 degrees Fahrenheit. The minimum in health is attained 
shortly after midnight, and the maximum in the afternoon. The 
temperature falls rapidly in the evening, about the time the child goes 
to sleep. It may range from 97 degrees Fahrenheit to 100 degrees 
Fahrenheit in the rectum in healthy children. 

The following table may be found useful as a guide : — 

Very low or collapse temperatures : — 

Below 35 degrees Centigrade, 95 degrees Fahrenheit. 

Below 36 degrees Centigrade, 96.8 degrees Fahrenheit. 
Subnormal temperature : — 

About 36V2 degrees Centigrade, 97.7 degrees Fahrenheit. 

About 37 degrees Centigrade, 98.6 degrees Fahrenheit. 
^NTormal temperature : — 

Xormal, 37 degrees Centigrade, 98.6 degrees Fahrenheit. 
Slightly above normal, or subf ebrile temperature : — 

About 37% degrees Centigrade, or 99.5 degrees Fahrenheit. 

About 38 degrees Centigrade, or 100.4 degrees Fahrenheit. 

About 38!/2 degrees Centigrade, or 101.3 degrees Fahrenheit. 
Moderately febrile temperature: — 

About 39 degrees Centigrade, or 102.2 degrees Fahrenheit. 

About 39yo degrees Centigrade, or 103.1 degrees Fahrenheit. 
Highly febrile temperatures : — 

About 40 degrees Centigrade, or 104 degrees Fahrenheit. 

About 40!/o degrees Centigrade, or 104.9 degrees Fahrenheit. 
Hyperpyretic temperatures : — 

Above 41 degrees Centigrade, or 105 degrees Fahrenheit. 
Very high temperature (above 106 degrees Fahrenheit) and 
very low temperatures (under 96 degrees Fahrenheit) are necessa- 
rily fraught with danger ; but a sudden rise of temperature (to 104 
degrees or 105 degrees Fahrenheit) may sometimes give ground for 
hoping that we are dealing with a trifling f ebricula ; on the other hand, 
a moderate temperature (102 degrees to 103 degrees Fahrenheit), with 



270 Diagnosis of Child re its Diseases. 

cerebral symptoms, may, just because of its moderation, give rise to 
the most grave apprehensions of a deadly meningitis ; whereas a higher 
temperature (say 105 degrees x>t 105% degrees Fahrenheit) might 
give reason to hope that the cerebral symptoms were dependent on an 
incipient pneumonia or some less fatal disorder. The figures must be 
interpreted not only in view of the other symptoms, but also in view 
of the other known facts of the medical thermometry. 

Pulse. — The pulse in childhood has ceased to be regarded as any 
great criterion of the degree of fever, having been, in a great degree, 
superseded by the use of the thermometer ; but the value in many other 
Svays is still very great. The pulse is a guide in estimating the gen- 
eral strength of the patient, although we are liable to make mistakes 
in relying unduly on this sign. The correlation of the pulse and the 
temperature is often very suggestive. At the beginning of enteric fever 
we may have a pretty high temperature (say 102 degrees to 103 degrees 
Fahrenheit) with almost no elevation of the pulse-rate, and the appar- 
ently cool state of the skin may lead the physician to omit taking the 
temperature at all. Toward the end of such a fever, the pulse may 
be higher in proportion than the temperature, and it may continue, 
probably through weakness, to be very high even after the deferves- 
cence is complete. 

A slowness in the pulse has often a great significance in the diag- 
noses of cerebral affections, and especially of meningitis. At the 
beginning of the illness, with distinct elevation of the temperature, we 
may find the pulse rapid; but with the advance of the disease, the 
temperature may fall, and the pulse may become extremely slow (say 
about sixty beats per minute). With the further advance of the dis- 
ease, after the temperature has become almost normal, we may find, 
a day or two before death, the pulse running up to an almost uncom- 
fortable height. 

Closely allied to slowness, is irregularity and intermission in the 
pulse. This, also, occurring with headaches, sickness, moderate fever, 
or other signs of meningitis, is always of grave import. The irregu- 
larity is of two kinds, and both are found in meningitis. We may 
have intermission in the pulse, a beat being lost every five or ten or 
twenty beats. This occurs also in brain diseases of various kinds. 

Irregularity and intermission of the pulse occur in other than in 
brain disorders, notably in cases of pericarditis in its early stage, and 
also in acute endocarditis. Probably on this account we have irregu- 
larity in the pulse not uncommonly in chorea. Of course, it is often 
present, as in the adult, in valvular disease of the heart. In extreme 
stages of feverish illness, a flickering, or irregular, or intermittent 
pulse, indicates the grave condition of the patient, but in such cases 
the diagnosis is already made, as a rule. 

Physiognomy. — The idea of defining special temperament and 
diathesis from the general aspect of the patient is now abandoned by 
most physicians. The significance of pallor as a sign of anaemia is 



Diagnosis of Children s Diseases. 271 

recognized, as in the adult, by a comparison of the color of the mucous 
membranes, or, if need be, by actual testing of the color of the blood, 
and by ascertaining if the general symptoms of anaemia, such as breath- 
lessness, giddiness, etc., are present, or by physical examination of the 
veins and heart for anaemic murmurs. 

The presence of jaundice in children is recognized as in the adult. 
Of this we will speak later on in this work. 

But apart from obvious jaundice, we sometimes see a dark com- 
plexion allied to it, leading one to feel that those with this "bilious 
temperament," as it is often called, are especially liable to digestive 
disorders, with a tendency to great feverishness and headache in such 
attacks ; while with a blonde or florid complexion we often see that 
children are especially liable to great cerebral excitement and delirium 
from very trivial ailments. 

The appearance of flushing in feverish illness of all kinds ; the com- 
bination of flushing and duskiness in suffocative bronchitis, advancing 
through various degrees to that of alarming lividity ; the combination of 
duskiness and pallor in the face with coldness of the surface; the suc- 
cessive redness, blueness, and blackness perceptible in bad paroxysms of 
whooping-cough ; the extraordinary blueness aggravated by crying, seen 
in the cyanotic state, "morbid cerulean," of children affected with con- 
genital malformations of the heart, — all these are physiognomic 
features of the utmost value. 

Sweating is a common feature in certain stages of febrile disease, 
whether in children or adults ; and the cold sweats of exhaustion also 
occur in childhood. But in rickety children very profuse sweating of 
the head and neck, especially when the child goes to sleep, may occur 
in the most extreme form without any fever whatever. 

Distention of the veins of the face and neck may occur to a notable 
extent in all forms of difficulty of breathing or dyspnoea, and in cases 
of croup the outstanding veins in the neck often form a serious impedi- 
ment in the performance of tracheotomy. The appearance of the child 
lying asleep with eyes half open, has, since the time of Hippocrates, 
been regarded as of bad omen, and indicative of grave brain disease; 
but now it is considered a mistake to attach much importance to this 
state of the eyes. 

The characteristics of the appearance of febrile rashes will be 
dealt with later on in this work. 

The Cry. — Crying immediately after coughing suggests the idea 
of pain being caused thereby, as in pleurisy, pneumonia, and some 
forms of bronchitis. A moaning is a clear indication of local suffering 
or of general distress, more so than the lusty cry of mere irritability, 
sleepiness, or bad temper. Crying, with wriggling movements of the 
pelvis and legs, has been regarded as a sign of colicky pain. Loud 
crying seems to be due to pain in the kidneys or bladder from gravel. 

Continuous crying or screaming is so often found to be due to 
earache that this should always be thought of in obscure cases; and the 



272 Diagnosis of Children s Diseases. 

result of the examination of the ears, or decided relief from hot nar- 
cotic applications, may clear up the diagnosis ; or perhaps the alarming 
symptoms simulating meningitis may disappear after the discharge 
of matter from the ears. 

In croupy affections the cry may be hoarse. A child is more likely 
to cry from thirst than hunger; especially in feverish cases is thirst 
much greater. 

The absence of crying is often of graver import than its presence. 
The sick child, ill and exhausted beyond endurance, may only wrinkle 
up the lips as if to cry, without any sound ; or in bad pulmonary cases, 
$r even in rickets, the child may not be able to spare the breath required 
for the cry; and in the stupor and coma of brain disease the child is 
only too quiet. 

After the child is three or four months of age, the absence of tears 
during crying is construed as a bad sign. Something of the same kind 
is often seen in adults. "The dying weep not." 



} 



CHAPTEK XIV. 
DIAGNOSIS OF CHILDBEDS DISEASES (Continued). 

DROPSY. 

Dropsical swellings are not very different in children from 
what they are in adults. General anasarca of renal origin is rel- 
atively common at this age, partly on account of the frequency of 
scarlatinal dropsy, and partly because of parenchymatous nephritis 
specially affecting young subjects. Whenever a child appears with 
suddenly-developed anasarca, we are bound to think of scarlet fever; 
we look for signs of desquamation on the fingers and elsewhere; and 
we inquire for a history of sore throat, red-rash, etc. Any mistake 
in missing the diagnosis of scarlet fever in such cases may be disas- 
trous as regards other children. Once in a while there is a case of 
genuine renal or scarlatinal dropsy without a trace of albumen in the 
urine. 

In scarlatinal dropsy, and, indeed, in other forms of acute or 
subacute nephritis in children, even it may be with dropsy, we must 
always be on our guard, lest a supervention of acute pleuritic or peri- 
cardinal effusion, or the occurrence of uraemic convulsions, should 
come on under circumstances which might aggravate the condition, 
or give rise to painful reflections of these being caused by indiscretions. 

The dropsy of heart disease does not differ in the young, in any 
notable manner, from what we see in the adult. 

Oedema of the feet or of the eyelids in young children is no uncom- 
mon thing as a result of anaemia, with, perhaps, feeble circulation, but 
without renal or cardiac disease. It may occur in chronic diarrhea 
or other chronic illnesses. We see a more peculiar form of the same 
thing in the swollen state of the hands and feet, the swelling being 
so tense as not to pit on pressure. A somewhat similar condition, 
with hardness and swelling more extensively distributed, has been 
described in newly-born or very young children, under various terms 
("induration of the cellular tissue," "sclarenie," "hi de-bound"). It 
may be complicated by a low temperature, and by great disability, 
and is indeed a most dangerous condition. 

As in adults, obstruction to the circulation in the chest may give 
rise to oedema of the upper part of the body and arms. In children, 
tumors in the mediastinum, giving rise to such symptoms, are usually 
of glandular nature. 

Subcutaneous emphysema, from the rupture of air-vessels in 
whooping-cough, or other diseases, may seem at the first glance to 
resemble oedema; but the crackling sound and sensation on testing 
the parts for pitting, and the resonant percussion, prevent mistake. 

(273) 



274 Diagnosis of Children s Diseases. 

GENERAL PAINS, AND PAIN IN THE LIMBS. 

Pain in the head, chest, back, or abdomen, when it can be local- 
ized by the child's language or signs, serves, of course, to guide our 
examination. At times they are present, but undescribed, and the 
only indications we get are from the expression of pain in the face, or 
from the cry, and from the apparent aggravation on moving or press- 
ing certain parts. Elsewhere, persistent crying has been spoken of 
as due to persistent earache. 

Sometimes the discomfort, as in the adult, is too general to be 
clenned, although extreme enough. In rickety cases, the tenderness is 
in the bones and muscles, and is developed on handling the child or 
disturbing his position. In cerebral meningitis, there is great general 
hyperesthesia, with special pains on moving the neck and limbs. In 
cerebral-spinal meningitis we sometimes have a complication of rheuma- 
tism, and cases of this alarming disease are sometimes put down as 
rheumatic ailments of no great severity, owing to the absence of any 
swelling in the joints. 

Rheumatism in childhood is at times rather difficult of recogni- 
tion, as the articular affection is only slight, and perhaps contemptu- 
ously spoken of as "growing pains," although such trivial attacks are 
often associated with endocarditis, leading to permanent mischief in 
the heart. At times the pains are almost limited to the feet and heels, 
with some stiffness in the muscles. In other cases, of course, acute 
articular rheumatism may be plain enough, but in children under six 
or seven years it is not common to have it in a glaring form. As in 
adults, pains more or less distinctly rheumatic may occur with an erup- 
tion of purpuric spots. 

Another disease, sometimes erroneously called rheumatism, is 
acute periostitis, or necrosial fever. In the early stages, this is often 
thought to be typhoid fever, when the pain in the limbs is trifling, 
and is often supposed to be rheumatism when the pain is more pro- 
nounced. The disease frequently advances to suppuration before it is 
recognized as periostitis at all. The tibia is the most common bone 
affected, but others also are attacked. 

The red spots of erythema nudosum may give rise to much pain 
with feverishness. They often occur in rheumatic subjects. 

The pain in the limbs in the early stage of infantile paralysis 
often leads to a misconception of the nature of the attack, and affec- 
tions of the joints may be suspected, and especially the diagnosis of 
the hip- joint disease is sometimes made, with, it may be, disastrous 
results in the subsequent treatment. But joint affections also occur 
only too frequently in children, with pain and swelling; scrofulous 
disease in particular must always be borne in mind. Although it is 
a rare affection, haemophilia, or the hemorrhagic diathesis, frequently 
gives rise to joint affections in children, with painful swellings, due 
probably to effused blood. 



Diagnosis of Children s Diseases. 275 

Glandular swellings are also scmrces of pain, especially in the groin 
and in the neck. In the latter situation, the pains arising from them 
may simulate rheumatic affections of the muscles, or they may give 
rise to distortions resembling tosticallis; from the violent shooting 
pains going up to the head, grave cerebral mischief may sometimes be 
apprehended. The glandular swellings are not always easily felt, but 
when enlarged and tender glands are detected, the explanation of pains 
and feverishness may be at once obtained in otherwise very alarming- 
looking conditions. 

FAMILY HISTORY HEREDITY. 

The family history is of capital importance in the study of chil- 
dren, for it is often by the known tendencies of the disease in the 
individual and in the family that we interpret the meaning of existing 
symptoms. 

The best way is to ascertain all the facts known to our informant 
regarding the ages of the parents and of the brothers and sisters, if 
they are alive, their state of health, and their liability, past or present, 
to any ailments. If there have been deaths, we ascertain the causes 
of death, and the age at death. We often require, also, to get particu- 
lars as to the duration of the illness and the leading symptoms, so as 
to compare these with the name assigned to the disease. In cases of 
suspected syphilis we have much light thrown on the nature of the ill- 
ness by a history of repeated abortions in the early months of preg- 
nancy ; then of still-births at the full time ; and then, as the intensity of 
the disease seems to lessen, of living children born with congenital signs 
of syphilis. After all such information is obtained, we have often to 
make inquiry as to other relatives, particularly the grandparents and 
the uncles and aunts on both sides. When we have definite suspicion 
of the nature of the illness, as in case of tubercular disease, rheuma- 
tism, cancer, diabetes, etc., we inquire especially as to these, giving a 
variety of names, so as to help our informants, asking if any such cases 
occurred among the relatives named. 

Tubercular tendencies are so important and manifold in the dis- 
eases of children that we have to make special search for them, includ- 
ing all sorts and forms we can think of, under various popular names. 
The influence of a mother's phthisis seems more potent than a father's 
in transmitting such an affection. 

In the case of cancer, with which probably other malignant tumors 
should be grouped for this purpose, we must remember that although 
affecting at times even very young children, cancer is notably a disease 
of advanced life, and that children may inherit the tendency from 
parents in whom, or in whose brothers and sisters, it may not yet have 
had time to appear, although no case may have occurred in the parents 
or in their brothers or sisters. The history of the grandparents and of 
granduncles and of grandaunts may come in to clear up the mystery. 



276 Diagnosis of Children's Diseases. 

This disease is always transmitted in the female line, but only to 
male descendants. 

In the case of the so-called ataxia (Freidereich's disease) we have 
the same nervous affection occurring in various members of a family, 
although the fact of actual transmission is not made out. 

The combination of the constitutions of the two parents may deter- 
mine peculiarities unknown to either of them. The injurious influ- 
ence of consanguineous marriages may also be explained in some such 
way, the influences for evil in a family being intensified, instead of 
lessened, by the marriages of near kin. Further, when both parents, 
although of different families, are consumptive or rheumatic or 
neurotic, the danger of transmission is no doubt much greater, if for 
no other reason than that there is thus a double chance of transmission, 
or a double portion of the same inheritance. 

In rickets the disease has often the appearance of heredity, from 
several children being affected in the same family, and it is notable that 
the later children in certain families seem especially prone to this 
affection. The explanation is probably not to be sought in heredity, 
except in so far as a mother of a large family in poor circumstances, is 
liable to have had her health run down by work, anxiety, and child- 
bearing ; but the children in such a family are, of course, all likely to be 
exposed to similar unhealthy surroundings, and with the increase in 
their number the mother is less able to take them out in the open air, 
or to attend to them in the special manner in which she could when 
there were only one or two in the family. 

Pseudohypertrophic muscular paralysis is notably a family dis- 
ease ; although not traceable in the parents of the affected children, it 
may show itself at times in the uncles as well as in the brothers of the 
patient. 

The tendency to transmission of a disease to children born after 
the parents have had the affection themselves, seems to be more potent 
than in cases where the children were born before the parents were so 
affected. In the case of syphilis in a father, we can see at a glance that 
it is only after the parent has had the disease that it can be transmitted. 
All the earlier children are quite unaffected. We can even understand 
that in the case of a mother actually affected with advanced consump- 
tion during her pregnancy, the child thereafter born is more likely 
to be affected than those who were born before the mother's health had 
broken down. But it is not so intelligible, it would seem to be made 
out, that in the case of gout, of rheumatism, and probably some other 
affections, the parents, although capable of transmitting these dis- 
eases to their offspring before they have had overt manifestations of 
them in their own persons, are more likely to transmit the diseases, or 
to transmit them to a greater intensity, to those born after they them- 
selves had been affected. 

Transmission of diseases and disease tendencies is not as yet fully 
worked out. We can easily understand that such manifestations as 



Diagnosis of Children's Diseases. 277 

hip-joint disease, tubercle in the brain, and tubes-mesenterica may all 
be reduced to one common inheritance, and that these occurring in the 
brothers or sisters of a patient, or in his uncles or aunts, may throw 
light on cases of mischief in the pleura, pericardium, or lung, or on 
many other tubercular affections in other members of the same family 
stock. 

Rheumatism, growing pains, chorea, and heart-disease form 
another group of hereditary ills, which may be classed with hysteria, epi- 
lepsy, and insanity. In many cases there is such a neurotic group ; and 
probably a liability to a bad or generalized neuralgia, bad headache, 
and general excitability should be included as the result of the inherit- 
ance of an unstable nervous system, which, however, is quite com- 
patible with great quickness of intellect and general ability. 

These nervous diseases seem to replace one another in the history 
of the individual at different periods of life, or in different members 
of his family. It is extremely probable that inheritance of a bad 
nervous system predisposes not merely to alcoholism, but also to crim- 
inal courses of life, and that children of drunkards and of the criminal 
classes come into the world biased toward evil courses, which may 
take the form in them of more definitely recognized diseases. 

Rheumatism has already been referred to, but it has also other 
affinities. The rheumatic and gouty inheritance may show itself in the 
children's being liable to psoriasis and eczema, to uric-acid gravel, and, 
it may be, calculus, or to asthma and to asthmatic bronchitis. Uric- 
acid calculus is a disease known to be often hereditary, without, per- 
haps, any connection with other diseases being ascertained. 

Gout is practically unknown in childhood in its articular form; 
but we may see the little pearly deposits in the ears ; and in addition to 
some of the ailments mentioned in the last paragraph, we may see 
granular kidney. In any case, this granular, or so-called gouty, kid- 
ney may appear as an hereditary disease in certain families, declaring 
itself even in early life. 

Saccharine diabetes in children, although rare, can often be traced 
as hereditary disease, as in the adult we can sometimes see a relation- 
ship between diabetes and phthisis pulmonaris, or other tubercular 
disease. 

Malformation of all kinds can often be traced, occurring in dif- 
ferent generations of the same family ; the same is true as to the family 
peculiarities of build and features. 

Intermediate between congenital malformations and inherited 
diseases we may place deaf-mutism and congenital color-blindness, 
although exact structural defect may evade our recognition. 

Catarrhal tendencies are undoubtedly transmitted. These may 
lead to wheezing condition in the chest or to nasal catarrh, favoring, 
for example, affections of the tympanum from this cause, with its 
attendant deafness, so often found to run in families. 

But, further, special families are liable to attacks of the acute 



278 Diagnosis of Children's Diseases. 

specific fevers ; and when they appear, there is apt to be a special sever- 
ity in the disease. We may thus trace a severe type of diphtheria or 
enteric fever, with perhaps grave intestinal hemorrhages, as occurring 
in different members or generations of the same family, at such inter- 
vals of time as to preclude the idea of any common infection, and yet 
with such frequency and severity as to make the idea of special liability 
irresistible. 

THE NERVOUS SYSTEM. 

Among the disorders in the nervous system we have paralysis 
in various forms, but some varieties common in the adult are rare at 
early ages. Thus hemiplegia from ordinary hemorrhages or degen- 
erations such as occur in advanced years, is scarcely known. But 
hemiplegia does occur, and is sometimes suspected to exist when the 
disorder is really due to something else. Thus in chorea, really a 
convulsive disorder, we usually have more or less of power, and when 
the affection is unilateral, the loss of power is unilateral also. When 
by some chance the twitchings are not very plain, or when, as happens 
rarely, but still occasionally, the loss of power precedes the twitchings, 
and the child is brought complaining of a somewhat sudden loss of 
power in one arm or in one side, we may, by careful examination, be 
able to make a diagnosis of chorea, and so remove much of the anxiety 
felt at such an occurrence. 

One-sided paralysis in children is often dependent on cerebral 
tumors, usually tubercular; but the presence of staggering and more 
general weakness often takes away from the precision of the hemi- 
plegia. In children with one-sided paralysis dating from birth, we 
must always think of the possibility of some hemorrhage or other 
lesion from injury to the head at parturition or birth. This is apt 
to be followed by atrophy of the brain on the affected side, and by 
a spastic state of the paralyzed side. A bilateral lesion may give 
at times a bilateral hemiplegia, if such a term may be used, with a 
most remarkable shuffling gait. Paralysis of one arm or of one leg 
(monoplegia) from infantile paralysis may occasionally suggest the 
idea of hemiplegia, particularly if the two limbs on the same side are 
implicated in the attack. The idea of a cerebral lesion may be sug- 
gested, although the disease is known now to be of spinal origin. All 
the more likely is such a mistake to arise if convulsions have ushered 
in the attack. Meningitis and abscess of the brain occasionally give 
rise to one-sided paralysis ; but usually the case is too complicated 
to be spoken of as hemiplegia. In whooping-cough we may have, 
although rarely, small hemorrhagic lesions in the brain, due proba- 
bly to the paroxysmal fits of coughing ; with these we may have aphasia 
as well as hemiplegia. Hemorrhage on the surface of the brain or 
into its membranes is more common than marked hemorrhagic lesions 
in the brain substance. When children with meningeal hemorrhage 



Diagnosis of Children s Diseases. 279 

survive the shock, there rnay be paralysis of one side, and the post- 
mortem examination may show the presence of false membranes. 

Paralysis of a limb, or of part of one side, is not very common 
as a sign of cortical lesions in the brain, often associated with con- 
vulsions limited to the same part. In the paralyzed limbs of hemi- 
plegiac children there is often a tremulous or shaky state, especially 
noticeable when the arm is used. Such cases are often due to cere- 
bral tumor. 

Paraplegia in children is usually dependent on caries of the 
vertebra, which is relatively common in early life. Its features are 
not specially different from those seen in the adult. Of course spina 
bifida may give rise to a form of paraplegia special to children. 
Diphtheritic paralysis is relatively common in childhood ; but it usually 
affects the palate, and the accommodation of the eye, more notably: 
it may assume the paraplegic type; or the whole muscular system of 
the body may seem implicated. Other specific fevers are also occa- 
sionally followed by paraplegia. 

Epidemic cerebro-spinal meningitis is not uncommon in children 
when the disease is present in a community. The most striking fea- 
tures, in addition to headache, vomiting, and fever, are the severe 
generalized pains in the back and limbs, with great suffering on han- 
dling the child ; the presence of retraction of the head and neck, which 
is often extreme ; the occurrence of herpetic or purpuric eruptions on 
the body, and the implication of the eye and ear. 

The pyrexia is more intense and persistent than in the ordinary 
tubercular-cerebral meningitis. After the lapse of a few weeks, recov- 
ery may take place from a condition which seemed quite hopeless ; 
but deafness or some other remnant of the disease may be permanent. 

Infantile paralysis, to its pains, feverishness, sudden loss of power, 
and rapidly developed atrophy and coldness of the limbs, etc., will 
be spoken of later on in this work. The localization of the paraly- 
sis, when not absolute or extreme,- is different in the upper and the 
lower limbs. In the arm, it is usually in the upper part, which is 
badly paralyzed, the muscles of the forearm and fingers regaining in 
time considerable power; in the leg, it is especially the muscles below 
the knee, which are weak and atrophied, those of the thigh being often 
pretty sound. As it well known, the sensation is not affected in infan- 
tle paralysis, and the sphincters almost never. Pain in the early stage 
of this affection often leads to erroneous ideas, suggesting hip- joint 
disease and various other painful disorders. Very often the true 
diagnosis is not suspected till the paralysis is detected, when the child 
is supposed to have recovered from the acute disease. 

A form of paralysis limited to children, or at least always begin- 
ning in early life, is the pseudohypertrophic muscular paralysis des- 
cribed by Duchenne. It tends to occur in certian families, although 
really a rare disease. The child begins to fall easily, and his com- 
panions often amuse themselves by knocking him over, as the process 



280 Diagnosis of Children s Diseases. 

of rising is difficult, and, in a sense, comical. The abdomen stands 
out, from the presence of the saddle-back curvature in the spine, and 
the child's manner of lifting the feet suggests a resemblance to the 
walking of a turkey. The limbs, instead of being wasted, appear as 
if hypertrophied, in the early stages at least, and the calves of the legs 
are especially prominent. The hypertrophy, however, is spurious, 
and the limbs are really weak. 

Aphasia has been found again and again in children, under cir- 
cumstances pointing to a lesion of the brain in the usual situation, 
but it is far from being so common as in the adult. 

Affections of the speech, and other symptoms closely resembling 
those found in bulbar paralysis, usually prove to be due, in children, 
to tumors involving the floor of the fourth ventricle, as the regular 
progressive labio-glossa laryngeal paralysis does not occur in early life. 

Paralysis of the cranial nerves is common in childhood. The 
portio-dura of the seventh pair of nerves is often involved in ear- 
disease at this age. In young children, this nerve may be affected from 
acute suppurative inflammation in the middle ear without destruction 
of the nerve, as proved by the subsequent recovery. The other causes 
of peripheral-facial paralysis are also operative in childhood, but do 
not call for a notice here. Facial paralysis of central origin occa- 
sionally dates from an obscure affection in early infancy, pointing 
to cerebral disorder. In this last case, the paralysis, although of old 
date, does not prevent the muscles from responding to the Faradic 
current perfectly. 

Paralytic affections of the ocular muscles, with squinting, immo- 
bility of the eyeball, lateral deviation, and nystagmus, are very com- 
mon in childhood in connection with cerebral tumors. These affec- 
tions must be studied and worked out in detail, just as in adults, so 
far as the child's condition and intelligence render this possible. In 
childhood the occurrence of squinting may be readily brought about 
by any acute illness, so as to occur at a particular time, although 
from errors in the refraction of the eye its appearance sooner or later 
might be inevitable. In such cases, of course, the squint is not para- 
lytic. 

Affection of the optic nerves comes under the head of specialities. 

Marked intolerance of the light, with spasms of the eyelids and 
lachrymation, always suggests the idea of keratitis or kidney trouble, 
and we may have photophobia from this cause without lachrymation. 
In various brain affections, and especially in meningitis, the child 
often shuns the light without any local affection of the eyes, the 
headache being intensified by any bright light. 

The state of the pupil has often to be examined in children. 
During healthy sleep, the eyeball is drawn upward and inward; but 
if the lid is raised, the pupil is found contracted. If the child awakes 
during this examination, the pupil dilates with the awakening, but 
contracts immediately upon its exposure to the light. Immobility of 



Diagnosis of Children s Diseases. 281 

the pupil on exposure to light may be taken as an index of blindness, 
if the pupil is of normal size. 

Enlargement of both pupils is common in cerebral meningitis 
with effusion into the ventricles, but, as in the adult, some of the 
most grave cerebral lesions produce contractions. Enlargement of 
one pupil is common in paralysis of the third nerve, usually with other 
signs of this nerve's implication. Inequality of the sympathetic, from 
paralysis, shows itself by contraction on the affected side, or rather by 
a want of dilatation on shading; it may occur in spinal cases involv- 
ing the cervical region, or from other implications of the sympathetic 
in the neck. 

Oscillation of the pupil under the stimulus of light, so that it con- 
tracts and dilates while the light is held steadily before the eye, 
is not uncommon in children with meningitis. In opium narcosis, 
contraction of the pupil is a valuable guide. 

Enlargement of the pupil from atropine applied locally, usually, 
of course, affects only one side, but during its internal administration, 
if pushed, both pupils are enlarged and somewhat imperfect in their 
response to light. 

Tubercular meningitis is one of the most alarming diseases of 
childhood, and in its early stages, one of the most difficult for diag- 
nosis. We will here make some allusions to the frequent difficulty 
experienced in deciding whether a case is one of meningitis or of 
enteric fever. In both we have fever; in both oppression or excite- 
ment, or, it may be, coma; and in both we have a congested state of 
the lungs. The points which aid us are: (1) That in enteric fever 
sufficiently severe to cause cerebral symptoms, the temperature is 
usually very feverish; whereas in tubercular meningitis, after it pro- 
duces marked cerebral symptoms, the temperature is usually moderate. 
(2) In tubercular meningitis the child has usually been failing in 
condition before the acute symptoms come on. (3) The state of the 
abdomen and bowels may guide us, not merely as to looseness, although 
this is so extremely uncommon in meningitis as to count for much, 
but more particularly as to the tumidity of the abdomen. It is rare 
that this is entirely absent in enteric fever, while in meningitis the 
abdomen is seldom full, often flat, and sometimes retracted. (4) The 
family history, and (5) the mode of onset also help us. 

Another condition sometimes confused with meningitis is "hydro- 
cephaloid disease/' due to exhausting illness, and especially to diar- 
rhea. In both diseases the child may lie in the same apathetic con- 
dition, with little or no fever. The history of diarrhea, with the vom- 
iting, may often guide us; for, as has already been said, this is a 
rare complication in meningitis. The collapsed fontanel in young 
children may also often guide us, for it is in them that mistakes are 
most likely to occur. 

Convulsive diseases are of special importance in childhood; for 
they occur not merely as complications of grave disorders of the 



282 Diagnosis of Children's Diseases. 

brain or from uraemia, as in the adult, but also as manifestations 
of general disorder and disturbance. Thus, in acute fevers or in 
pneumonia, there may be convulsions ushering the illness or occurring 
during its progress. As Dr. West puts it, "In a large proportion of 
cases, convulsions in the infant answer to delirium in the adult.'' 
This is a most suggestive view, when taken in connection with the 
demonstration of motor centers in the cerebral convolutions. But in 
early life errors in diet or disorders in digestion, which in adults 
might be called trivial, may give rise not only to diarrhea or vom- 
iting, but to violent convulsions. ~No doubt some special susceptibility 
may exist in the nervous system to favor such an occurrence in some 
children or families rather than in others; and in connection with 
rickets, this predisposition undoubtedly exists in many, so that trivial 
disturbances, not always easy to trace, reveal themselves by convulsive 
attacks. In connection with violent spasms of the glottis — itself a 
convulsion — whether in whoping-cough or in laryngismus stridulus, 
we often see general convulsions supervening. In cases of prolonged 
diarrhea or other forms of exhausting disease, we may have convulsions 
apparently in the same way as from the loss of blood. 

Scarlet fever may have been so slight as to pass unrecognized, 
or at least to be little regarded ; the renal complications may also have 
been little, if at all, thought of, till sudden ursemic convulsions may 
startle all concerned. Those physicians who have been once surprised 
are usually very careful to see that nothing is wanting in the care of 
scarlatina convalescents. 

Convulsive movements of the face and limbs, with erratic 
behavior of the voluntary muscles when called into action, are char- 
acteristic of chorea. This is essentially a disease of childhood. It 
may, however, appear in those who have attained puberty in both sexes, 
although very uncommon in young men. It is less rare in girls of this 
age, but usually then occurs as a relapse. It is well known, also, that 
it may complicate pregnancy, usually as a recurrence. However, not 
a few diseases, termed chorea, are entitled to be called so. The post- 
hemiplegic chorea already referred to, which is not limited to children, 
clearly points out grave mischief in the brain; and, no doubt, some 
other of the chronic forms of chorea point in the same direction. 
Occasionally a tremulous, jerky state of the arm may simulate chorea 
pretty closely, although really constituting an early symptom of cere- 
bral tumor. Whenever chorea departs from its known characteristics 
as regards age, duration, localization, and concurrent symptoms, we 
must always suspect that something worse may be actually present. 

We will not discuss the diagnosis of epilepsy here, but will else- 
where. 

A remarkable form of convulsion limited to children is that known 
as eclampsia nutans. These "nodding convulsions" usually consist 
in the rapid bobbing of the head up and down or backward and forward. 
The disease is probably closely allied to epilepsy, and like epileptiform 



Diagnosis of Children s Diseases. 283 

seizures of the more ordinary kind, these nodding fits are probably at 
times due to the presence of tubercles in the brain. 

The curious spasms of the fingers and toes, or of the wrist and 
feet, known as "tetany," may be regarded as almost special to chil- 
dren, although they occur in others also, especially in nursing women. 
Occasionally a graver or more continuous form, resembling tetanus 
more closely, may occur in childhood. Slighter forms, again, of these 
"carpo-pedal" spasms are often detected as manifestations of partial 
convulsions or as the precursors or remnants of general eclampsia. 
In connection with wasting diarrhea, a chronic spasm of these parts 
is often associated with the swollen state of the backs of the hands 
and feet, due, apparently, to anaemia. In such cases, the nervous 
affections may pass off as the general state improves, without any 
generalization of the spasms. 

Hysteria is by no means precluded from our diagnosis by early 
age. It may occur even in young boys. 

Of mental disorders, idiocy and imbecility are the most important 
in childhood. These defects cover a multitude of special ailments, 
such as inability to speak, to walk, etc. Violent maniacal fits after 
epileptic attacks, or replacing them, it may be, are likewise well known 
in children. A certain passionate violence in children sometimes 
goes to such a length as to suggest hysterical mania or some other 
instability of the mental faculties. In some cases, similar attacks are 
connected with uric-acid diathesis. 

In this connection, but short of any serious mental aberration, 
may be classed the terrible "nightmare, or night terror," of young 
children, arising from the vividness of their imaginations, coming on 
during night, probably in connection with dreams. Somnambulism 
also in various forms and degrees occurs in children, or excessive talk- 
ing in bed when asleep, or it may be with the eyes open. In this con- 
dition the child may be able to answer, in a kind of way, various ques- 
tions directed to it. These conditions of sleep-walking and sleep- 
talking are often dependent on, or at least aggravated by, undue appli- 
cation to study or continuous anxiety in connection with the studies. 

Headaches in children will be discussed in a special chapter. 

PULMO^AEY AXD CARDIAC SYMPTOMS. 

One of the most striking symptoms in disorders of the respira- 
tory system in childhood, consists in the appearance of rapid or labored 
breathing, with excited action of the alae of the nose, so that when 
we see this, with heat of the skin, we can scarcely go wrong in alleging 
a respiratory disease or complication. Another very striking fea- 
ture of respiratory distress in children at the breast, consists in their 
giving over sucking or in their readily abandoning the attempt, 
although, perhaps, eager to try. They have not breath enough to 
suck the breast, and may even be unable to suck the bottle, although 



284 Diagnosis of Children's Diseases. 

this is a less taxing effort in such condition. When this inability is 
reported, we always think of pneumonia or severe bronchitis. 

We have already referred to violent efforts at inspiration occur- 
ring in croup; but the presence of stridor in respiration, with a curi- 
ous hoarse or squeaking sound, and the hoarse, yet clinging sound in 
the cough, with, at times, a similar hourseness in the voice, constitute 
points of equal importance in the diagnosis.. Some of these croupy 
attacks, although alarming to look at, are practically devoid of danger ; 
the affection being only an attack of catarrhal laryngitis aggravated 
by spasms. In cases with deposits in the larynx or trachea, on the 
other hand, the danger is always great. The alarming dyspnoea in 
such children is more constant, never quite relaxing even for a moment, 
although in them the element of spasms is clearly present, aggravat- 
ing the permanent obstruction. The throat should always be examined 
for diphtheritic patches ; but there is often laryngeal diphtheria with- 
out any of the affections of the fauces. 

Occasionally retropharyngeal abscess gives rise to symptoms some- 
what similar to croup, and so the case may be misunderstood. Spasms 
of the glottis from nervous causes or from foreign bodies in the wind- 
pipe may also do so. 

Sometimes very rapidly-increasing pleural effusion, especially in 
a scarlatinal nephritis, may produce the most powerful efforts at 
respiration, resembling the paroxysms of asthma rather than croup. 
The sniffling noises in the nose with the respiration, from congenital 
syphilis, constitutes a well-known sign of much importance. 

In children, the absence of sputum of the respiratory organs is 
habitual. In chronic pulmonary phthisis with excavation — usually in 
children over five — we may, however, have the well-known nummular 
and globular sputa. Even cough is often absent or obscured in many 
cases. A peculiar squeaky cough is heard sometimes in bed, from 
pleuritic accumulations threatening suffocation. In empyema, chil- 
dren sometimes spit up the pus from the pleura with a favorable result. 
The aspect of children as regards lividity and flushing has already 
been mentioned. The decubitus, or lying-down position, is similar 
to that in an adult, and has similar variations, or is even more varied, 
from the restlessness of youth. In bad pleural effusions the child 
lies on the affected side. 

The rhythm of the breathing is sometimes very irregular in chil- 
dren. Irregular or sighing respiration is frequent in cerebral affec- 
tions, especially in meningitis. This is usually characterized by a 
few slow, shallow breaths, almost imperceptible, followed by a deep 
respiration. At times the implication of the breathing is a terminal 
phase of a case of cerebral tumor, the breathing stopping while the 
pulse is good; it may be even possible to re-establish the breathing 
for a time by artificial means. A certain slowness of respiration 
is very common in cerebral cases. Occasionally this altered rhythm 
becomes a regular in its irregularity,'' the ascending and descending 



Diagnosis of Children's Diseases. 285 

series of respiration, with, a period of apncea, described as "Cheyne- 
Stokes' respiration/' being perfectly marked in cases with gross cere- 
bral lesions; but this same irregular respiration may occur in cases 
not primarily of a cerebral nature, and it is frequent in grave cases 
of enteric fever with cerebral symptoms. The writer has seen the 
perfect Cheyne-Stokes' respiration in an infant overwhelmed with the 
poison of scarlet fever. 

The irregular breathing of opium narcosis, perhaps from an 
overdose of medicine, must likewise be mentioned. It resembles the 
cerebral breathing just referred to, but is more characterized by inter- 
missions in the breathing than by irregularity or by any definitely 
altered rhythm. 

In chorea we often see a very marked irregularity in the breath- 
ing, both when the child is lying quietly and when it is trying to speak 
or swallow, the management of breathing, as regards to time, being 
so far out of control as to prove troublesome in these actions. In 
rickets we have often a very great increase in the rate of respiration, 
so that it may run up to fifty or sixty in a minute, and this not only 
in connection with catarrh and slight pneumonic attack, but apparently 
as the normal condition of the rickety child's respiration. 

In auscultation and percussion, we have the same general facts 
as in adults. Clinking percussion and the "bruit skodique" are rela- 
tively common in childhood during advancing and receding pneu- 
monias and pleurisies, and the greatest care must be observed. Beware 
of making a diagnosis of cavity from the "cracked-pot sound" in the 
case of an infant, unless supported by other strong evidence. 

Phthisical disease of the lungs is much more common in early 
life than it was formerly supposed to be. We must not suspect, how- 
ever, the same great liability of the very apex of the lung to be involved 
as in adults. This and the implication of both sides in the consoli- 
dation help to make the diagnosis more difficult, and we have to rely 
much on the general aspect, the cpurse of the case, and the family 
history. 

Bronchial phthisis is often suspected in the case of children with 
a suspicious appearance and history of phthisis, when auscultation gives 
but little signs of pulmonary softening. We may have tubular breath- 
ing between the scapulae ; dulness or percussion there and at the upper 
part of the sternum; and perhaps loud fits of coughing, with almost 
a crowing respiration, resembling pertussis. Occasionally, in such 
cases, cheesy, fetid masses are expectorated. 

Bronchitis is seldom difficult of recognition, from the presence of 
wheezing, snoring, or moist rales, or of all kinds mixed up together. 
The very high-pitched, wheezing sounds suggest, of course, the finest 
tubules as indicated. 

Pneumonia is, however, very difficult of recognition. In the 
lobar form, this arises from the physical signs frequently being late 
in appearing, so that although the disease may be suspected and care- 



286 Diagnosis of Children s Diseases. 

ful watch kept on the chest, day after day may pass without physical 
signs, and thus the violent fever, delirium, and other forms of nervous 
excitement may lead to the suspicion of cerebral inflammation, espe- 
cially if the child passes into a kind of comatose state. The physician, 
now thrown off his guard, may have given over the exploration of the 
chest at the very time physical signs could be made out; and when 
hope is almost given up, in view of meningitis, we may see the child 
recovering, and perhaps a troublesome cough coming on for the first 
time. The clue to the case is often found in the very violence of the 
fever, and of the symptoms generally, at the outset ; for with the ordin- 
ary meningitis, pronounced cerebral symptoms usually coincide with 
comparatively moderate fever. 

Cerebral excitement from pneumonia has been supposed specially 
common when the disease affects the upper lobe. In such cases, the 
pneumonia is of the lober or croupous form. It is of special impor- 
tance to recall this situation of the disease, as experience in the adult 
leads us to search for pneumonia as rather at the base. In children 
the localization of the disease in the upper lobe has not quite the 
gravity in indicating a tubercular origin, as in the adult. 

In broncho-pneumonia, which may also simulate cerebral affec- 
tions, the lobules are involved in the catarrhal process, and so the 
physical signs vary much in distinctness. If extensive, we have dul- 
ness, tubular breathing, etc., as plain as in the other form; but if 
the condensed patches are small and scattered, the physical evidence of 
their presence may be obscure, and the signs of fluctuating, one day 
pretty clear, another day scarcely recognizable. One day we may 
think the right lower back is the site of the disease, the next day we 
may think the dulness and alteration in breathing is in the left. One 
day the whole side may seem implicated, another, only the base. The 
auscultatory signs vary much. Often we have tubular breathing more 
or less marked. Sometimes there is rather feebleness of the breath 
sounds. If either of these changes coincides with distinctly appreciable 
relative dulness in the back, however slight, fine, moist rales, rapid 
or labored breathing, excited action of the nostrils, and high tempera- 
ture, we may put the case down as pneumonia in some form. Having 
done so, we do not readily change our opinion, although the physical 
signs may seem to become less amidst the persistent fever. 

Judging from the signs just enumerated, we may think a broncho- 
pneumonia impending, or already begun, when the sequel shows that 
whooping-cough is the real disease ; but the local conditions in the 
lungs are probably closely allied to the other condition if much fever 
exists. Even in the course of a moderate case of whooping-cough, 
the signs referred to may all be present, and may almost completely 
disappear for a time after a fit of coughing, with or without vomiting. 

In childhood, collapse of the lungs plays an important part in 
the changes brought about in bronchitis and catarrhal pneumonia ; 
but patches of collapse, sometimes of large extent, may occur without 



Diagnosis of Children s Diseases. 287 

much concurrent inflammation, especially in whooping-cough. The 
signs are dulness on percussion, feeble respiration, partial immobility 
of the affected side, and by and by there may be a falling of the ribs, 
either permanently or only for a time. 

With regard to special auscultatory signs in childhood, the same 
harsh inspiration is natural to children. The occurrence of tubular 
"puerile breathing" will recall the fact that a very full and somewhat 
breathing in pleuritic effusion, especially at the back, instead of the 
feeble or suppressed respiration not often looked for, seems to be 
relatively more frequent in children than in adults, so that we are 
apt to make a diagnosis of consolidation of the lung when there is 
really a pretty large effusion in the pleural cavity. 

In pleurisy we may frequently miss in the child the initial fric- 
tion sound; indeed, the diagnosis at this age has usually to be made 
on the ground of pain in the side with restriction of the breathing 
without any audible friction. In a day or so we may have our diag- 
nosis confirmed by the presence of dulness on percussion, at the base 
behind, with feeble respiration and diminished vocal resonance. 
With the subsidence of the effusion we may have the friction audible 
for the first time. 

In cardiac diagnosis we have the same phenomena as in adults. 
Affections of the heart in children are very much more common than 
was formerly supposed. We must remember the occasional occurrence 
of congenital malformations with signs of stenosis of the pulmonary 
artery and other indications of defective development. There may 
or may not be concurrent cyanosis. We may practically exclude aneu- 
rismal disease from our diagnosis of cardiacal diseases, although dila- 
tation of this kind has been seen at this age. With regard to pericar- 
ditis, we may, of course, have it in acute rheumatism ; in case of chorea, 
also, with or without distinctly rheumatic symptoms, pericarditis may 
supervene, always a most grave complication in this disease. In young 
subjects the tubercular form of pericarditis is relatively more common 
than in adults. 

With the extension of pleuritic inflammation so as to give rise 
to pleuro-pericardial friction of genuine pericarditis, we are often in 
doubt as to whether there may not be a tubercular basis for the exten- 
sively distributed mischief. The course of the case alone can decide. 
The pericarditis of Bright's disease must also be remembered. 

A very special variety of pericarditis may be said to be limited 
to young subjects, essentially of pysemic origin, but developed in con- 
nection with "acute phlegmonous periostitis." This usually involves 
the tibia, but other long bones may suffer also. In such cases peri- 
carditis seems to mark the constitutional affection. It may persist for 
a long time, or it may be rapidly fatal. With the pericarditis we have 
often endocarditis also, and the disease in the valves giving rise to 
further dangers and complications, such as pysemic emboli in the kid- 
neys, etc. 



288 Diagnosis of Children s Diseases. 

In children, perhaps, even more than in adults, rheumatic peri- 
carditis may suddenly become highly dangerous from the excessive 
effusion, but the sign is not peculiar at this age. 

DIGESTIVE SYSTEM. 

The disorders in the digestive system are full of peculiarities in 
children, and especially in infants; but just on this account, we may 
deal with them slightly in this chapter, for in connection with wean- 
ing, artificial-food diarrhea, etc., the reader will find all the matters 
of special importance enlarged on elsewhere. The undigested milk 
^and curdy motions; the aspect of the fseces, when, as sometimes, they 
are green when passed, or sometimes only become green when exposed 
to the air; the influence of feeding in determining a motion, so that, 
as the nurses say, "the milk seems to run through the child at once;" 
the dreadful smell of the motions at times, and the controlling influ- 
ence, in this respect, of boiling the milk; the tenacity of the curd as 
vomited by the infant — the importance of these and of many other 
such matters has to be learned, and they can be sought for in another 
chapter. 

The significance of vomiting, and especially of persistent vomit- 
ing, in the child, has even a wider range — wide as that that pertains 
to disease of the digestive system itself. Vomiting is extremely com- 
mon at the beginning of the acute fevers; and if carefully inquired 
for, it will be found that it is very usually present at the onset of 
scarlatina. Even with pneumonia it is very common, and with vari- 
ous other serious febrile illnesses. It is, however, as the index of men- 
ingitis or other cerebral affections that it is most anxiously considered 
by physicians when called to a case of persistent or very frequent vom- 
iting. Again and again we try to explain it away as due to some 
digestive derangement, to the use of purgatives, or to the want of 
them, to errors in diet or in management, and the like, but we are 
forced to admit that these explanations are untenable, and that we are 
dealing with the vomiting of incipient brain-disease. At other times 
we may have the greatest anxiety as to the significance of such vom- 
iting, till the whole disturbance subsides without further mischief. 
From this it will be gathered that we know of no special points by 
which cerebral can be discriminated from vomiting of other origin. 
We aim at discovering if the vomiting had any obvious cause in the 
diet of the child, or if the tongue and state of bowels point to dis- 
orders there. We try to make out if the vomiting was preceded by a 
feeling of nausea for some time before it occurred; for it is when 
the vomiting seems most "causeless," in these respects, that we sus- 
pect a cerebral cause. We further attach great importance to the 
concurrence of severe headache with the vomiting and even to 
the concurrence of headache with any special turn of vomiting. 
The state of the temperature will also guide; for if suddenly rising 



Diagnosis of Children s Diseases. 289 

very high, we rather think of some impending fever, the elevation 
being, as a rule, very moderate in tubercular meningitis. The state of 
the bowels may guide us; for if there is concurrent diarrhea, the 
chances for meningitis are very small, since this disease is usually 
attended with constipation, and further, the looseness points to diges- 
tive disorders likely of themselves to cause vomiting. If constipa- 
tion is present, this, in meningitis, can usually be overcome after a 
little trouble, by physic ; but if it be intractable, both constipation and 
vomiting may be due to intestinal obstruction of some kind. The state 
of the abdomen may guide ; for if obstruction exists, some distention 
is usually present, but in meningitis there is no distention, and, indeed, 
in the course of the case we may even have retraction. Very often 
we can only wait, holding possibilities in view and trying to steer a 
course, as regards treatment, which will be as free as possible from 
objection, whatever the eventualities may be. 

Intestinal obstruction has just been referred to as a cause of 
vomiting. While all forms may occur in childhood, we must remem- 
ber that intussusception is relatively common in infants and children, 
and the presence in the intestinal discharge of blood, the discovery 
of a tumor in the abdomen, or an examination of the rectum by the 
finger, may clear up the cases which were doubtful till such assistance 
was obtained. Another cause of intestinal obstruction in childhood 
which is apt to give rise to mistakes and confusion, from the rarity 
of such accidents in adults, is the presence of tubercular peritonitis. 
Of course it is well enough known that in this condition there may 
be troublesome constipation; but at times we have, apparently from 
the agglutination of adjacent coils of the intestines, a distinctly 
mechanical obstruction produced, revealing itself not only by general 
abdominal distention, but also by violent peristalis of the coils of the 
bowel above the obstruction ; this being visible through the abdominal 
wall, as in many cases of abdominal stricture of the intestines. 

An examination of the mouth reveals at times disorders so com- 
mon in childhood as almost to be called peculiar; viz., stomactitis in its 
various forms. We may have little blisters, with clear fluid, on the 
tongue and mucous membrane of the mouth, or the spots may be 
rather like little superficial ulcers. In either case the salivation may 
be extreme, and there is often great fetor of the breath, and the whole 
digestive system is deranged. Another form of stomatitis is the gan- 
grenous {noma cancrum oris), in which the edges of the mouth on 
one side become black. The disease may also involve the gums, the 
teeth falling out, and great destruction of the parts often results. This 
destructive disease usually follows measles or some general, or at any 
rate, occurs in connection with some great constitutional, depression. 
A similar gangrenous disease may attack the vulva in little girls. 
Another form of stomatitis is the parasitic, formerly, and even now ; 
spoken of as aphthous ; its popular name is "thrush." In this we see 
white patches on the tongue, on the inner side of the cheek, or on the 



290 Diagnosis of Children s Diseases. 

throat. It is specially prone to occur in infants reared artificially, and 
assumes its greatest intensity in such when they are reduced to the last 
stages of wasting. Under the microscope, the thallus and spores of 
the Oidium allicans may be recognized. At times it presents, when on 
the fauces, a certain resemblance to diphtheria. 

The examination of the throat has greater importance in children, 
because we can not always be guided by them to the seat of their pain. 
A tonsillitis may at once explain the existence of a violent febrile dis- 
turbance ; or with a suspicious scarlet rash the appearance of the 
throat may at once enable us to declare scarlatina. In other cases, the 
presence of the white patches of diphtheria may explain otherwise unin- 
telligible illness. 

The discrimination of the various forms of sore throat is far from 
easy; often, indeed, it is impossible. Redness with patches of exuda- 
tion, so-called ulcers, on the tonsils, coincident with high temperature 
and a uniform scarlet rash, we must always regard as scarlatina; but 
when the rash is measly rather than of uniform scarlet color; when 
the throat is a little red but not very red, and quite destitute of patches, 
and when the rash is very bright and abundant, and the temperature 
only slightly elevated, we get into great difficulties. Sometimes the 
so-called German measles (rothelin, epidemic roseola) may be the 
cause of the symptoms. At other times, with slight rashes and no 
sore throat, we may be in the presence of a trifling erythema, or per- 
haps of a rash due to some special surgical dressing, or to some internal 
remedies which are being used. 

Tonsillitis with patches may occur without any connection with 
scarlatina, but it may also precede, but only for a day, the appearance 
of the scarlet rash. We may, however, miss the rash if very evanescent, 
or if search had not been made in time for it. Probably scarlet fever 
may affect the child ano^ its throat without any rash appearing at all; 
and also a sore throat may appear as a local manifestation of the poison, 
particularly in those already protected by an attack, without the whole 
system being contaminated by the contagion. 

Similar difficulties beset the diagnosis of diphtheria. When well 
marked, nothing is more easily recognized ; thus we may have the white 
membranous exudation on the uvula, palate, and tonsils, with regurgi- 
tation of the fluids through the nose, moderately high fever, and albu- 
minous urine. But in case of one or two insignificant white spots, 
like follicular tonsillitis, we may subsequently find, either in some case 
or in another member of the family, that the trivial-looking illness 
was the fatal diphtheria. All such cases should be treated with care, 
and all should be labelled as more or less infectious, although it is 
not necessary to declare the existence of diphtheria openly till the 
symptoms or the sequel make it certain. 

Itching at the nose and anus, and grinding of the teeth in sleep, 
have been regarded, with justice, as evidence of gastro-intestinal irri- 
tation. The first, indeed, has acquired a reputation as diagnostic of 



Diagnosis of Children s Diseases. 291 

intestinal worms, especially when combined with pallor and wasting, 
notwithstanding a good appetite. It is certain that picking the nose 
is very common in a multitude of cases where no worms appear. 
Itching and scratching at the anus, if quite pronounced, are very sug- 
gestive of "seat-worms" (Oxyurides vermicularis) ; but even then delay 
should be had till, after a purgative or an enema, the little worms are 
actually seen. 

The "round worms" passed by children, or sometimes vomited by 
them, seem often to be expelled rather because of the child's illness 
from some other cause, than to be themselves the cause of the acute 
attack. Sometimes they lodge in enormous numbers in the intestines 
of unhealthy children. Tapeworms infest even quite young children, 
occasionally. Here, too, segments of the worm must be seen to war- 
rant a diagnosis. 

Toward the beginning of this chapter there are warning words 
against teething being regarded as a cause of disease ; but these remarks 
do not warrant any neglect in ascertaining the actual state of the denti- 
tion, a subject to be fully discussed in another chapter. In connec- 
tion with the physical examination of the child, some remarks have 
already been made in the present chapter on peritoneal effusions and 
on glandular diseases in the abdomen. 

GENITO-URINARY SYSTEM. 

Disorders in the genito-urinary system present fewer points call- 
ing for notice than in the cases of the physiological system. 

The occurrence of renal affections after scarlatina is in this con- 
nection one of the most important considerations, and general dropsy 
or albuminaria in the young should always make us think of this, 
although, apart from any fever, parenchymatous nephritis is specially 
prone to affect young subjects. The other forms of Bright 's disease 
likewise occur in children ; contracted kidney occasionally, and ama- 
loid kidney frequently. In grave cases, it is always well to examine 
the urine for albumin and sugar, and by the microscope. To do this 
it will often be necessary to have recourse to the catheter, if a sample 
can not otherwise be obtained. 

Gravel in the urine probably accounts for many painful attacks, 
with screaming ; but it is only when we can recognize that the pain is 
with micturition, or when we see the uric-acid crystals soon after water 
is passed, that we may be able to make the diagnosis. Occasionally, 
there is no doubt, renal colics are quite unrecognizable in our young 
patients, although the urine, if charged with uric acid, or if mixed 
with blood, may guide the treatment. When the stone is in the blad- 
der, painful micturition, with blood, especially at the end of the act, 
or the occasional stoppage of the stream, or the presence of pus or 
mucus in the urine, may help the diagnosis ; but this can be made 
certain only by sounding the bladder. Vesical calculus in children 
is almost alwavs limited to males. 



292 Diagnosis of Children s Diseases. 

Pyelitis occurs in childhood. It may arise from a calculus, but 
probably is caused more often by scrofulous deposits in the pelvis of 
the kidney. The diagnosis is to be made as in the case of adults. 

Hydronephrosis occurs in children, and may indeed be congeni- 
tal. The presence of a tumor, and its variations in size, with great 
alterations in quantities of urine passed, may guide the examination. 
Cancer or sarcoma of the kidney often attains to an enormous size in 
children, with great swelling of the superficial veins, and the most 
extreme wasting. 

Diabetes, both in the saccharine and in the insipid form, is found 
in childhood. The saccharine variety is at times clearly traceable as an 
heredity affliction. The diagnosis is made as in the case of adults ; 
but in childhood the prognosis of diabetes mellitus is the worst possible. 

Polyuria from granular and amyloid kidney must be remembered 
in making the diagnosis of diabetes insipidus. 

Urinary sediments in childhood, apart from pus blood, casts, and 
epithelium, usually consist of urates, or uric acid. Both deposits are 
oftener much paler than in adults, and white urates, sometimes with 
hedgehog crystals, are frequently responsible for the milky urine so 
often described by mothers and nurses. Occasionally, of course, the 
milkiness may be due to pus. Uric-acid gravel is comparatively com- 
mon in childhood. Oxalates are often seen, likewise, in the sediment. 
Occasionally systine is found in the urine of children, sometimes with, 
and sometimes without, the occurrence of calculus. Cystinuria, 
although really rare, may be found in several members of the same 
family. Cholestrin in the urine is very rare. 

Wetting the bed at night (anuresis mycturia) may be regarded as 
essentially an affection of childhood. It will be discussed elsewhere, 
but it is mentioned here more especially because the passing of water 
in bed may be the only available sign of an epileptic fit occurring dur- 
ing the night. 

Disorders of the sexual organs need not detain us. The pre- 
cocious development of them in childhood has already been mentioned. 

The irritation of a phimosis or its influence in determining mas- 
turbation or enuresis is oftener a matter for inquiry, or for surgical 
operation, which was especially mentioned in the introductory. 

In girls the occurrence of vulvitis and of purulent discharges from 
the genital passages may at times raise very difficult and disagreeable 
questions. These have also been mentioned in the introduction, but 
will be discussed in a separate chapter. 



CHAPTEE XV. 

MATEENAL IMPKESSIONS. 

From time immemorial there has been a popular belief that 
impressions made upon the mind of a pregnant woman would cause 
defects in the child with which she was pregnant at the time. 

In the well-known instance related in Holy Writ, there seems to 
have been no expectation on Jacob's part that the Almighty would 
interfere directly to cause the flocks of Laban to bring forth young "ring- 
streaked, speckled, and spotted;" but the device that Jacob resorted to 
is mentioned in such a way as to show a belief at that time in maternal 
impressions. 

It was only comparatively recently, as the present age of skepticism 
approached, and thinking men came to doubt the truth of those things 
which they could not understand, that the power of these maternal 
impressions began to be questioned. Whether maternal impressions 
bear a causative relation to foetal defects, is one question; how such 
impressions act in producing the defect is another ,and a totally differ- 
ent question. 

In this article we will review some of the evidence upon which the 
theory of "maternal impressions" rests, and see what grounds there are 
for the popular belief which is so common to all nations, and kindreds, 
and people. 

We will omit all "hearsay" testimony, and will endeavor to take 
into consideration only that which we have from reliable sources. 

Much confusion exists also as to the nature of the defects attribu- 
table to maternal impressions, as well as to the nature of the impressions 
themselves. It is, therefore, important that the subject should be sys- 
tematically studied before any definite conclusions can be reached. 

There are two classes of defects which have been attributed to 
maternal impressions, — mental defects, and bodily defects. They 
should be considered separately. 

Mental defects in the child may be due to violent emotional dis- 
turbance of the mother during her pregnancy. This is generally 
acknowledged by those who have given most attention to the subject; 
and yet the cases of this character which have been recorded are few 
in number. History and tradition, it is true, furnish a number of 
instances of the kind. 

Sir Walter Scott, for instance, mentions that James I could not 
stand the sight of a drawn sword; and a gallant gentleman who was 
knighted by James makes the same statement, and acknowledges after- 
ward that he was apprehensive at the time lest the king should let the 

(293) 



294 Maternal Impressions. 

sword fall upon his shoulders, with the wrong side down. The mon- 
arch's apprehension was attributed to the fact that prior to his birth, 
his mother had seen Rizzio cut down in her presence. 

Dr. E. Seguin, well known as an authority on the subject of men- 
tal affections, stated that it was a well-known fact that an officer of the 
first Napoleon, as to whose courage there could be no question, became 
pale. when he saw a naked parlor sword. The explanation was that 
his father, in a fit of jealousy, had nearly killed his mother with such 
a weapon during her pregnancy with Napoleon's future officer. 

Dr. Seguin reported at the same time another case which came 
Under his own observation and care. A girl, who at the time that he 
knew her was twelve or thirteen years old, was a congenital idiot. The 
other members of the family, which was a large one, were above the 
average in point of intelligence. The mother was pregnant with this 
idiotic child during the civil war of Paris, and was harassed with 
anxiety for the safety of her husband. 

The well-known statement of Baron Larrey with respect to the 
siege of London, in 1793, is most striking, and yet it is by no means 
certain that the results were attributable solely to the fear and distress 
of the women, for the privation and suffering also were extreme. Of 
ninety-two children born in the district soon afterward, sixteen died 
at birth ; thirty-three died within ten months ; eight became idiotic, or 
rather, it should have been stated, perhaps, were idiotic ; and two were 
born with several bones broken. 

So far as we are able to judge from the limited data at hand, it 
would appear that a prolonged impression is far more liable to influence 
the foetus than a short one, even though the latter may be more violent. 
It is especially difficult to reach any conclusion on this point, however, 
because in many instances a sudden and violent shock was followed 
by a long period of distress. 

The character of the impression is of great importance. Anxiety 
and grief seem to hold the first place, and fear the second, with respect 
to the frequency with which maternal impressions influence the mental 
characteristics of the child. So far as we can learn, no case of sudden 
or excessive joy has produced any appreciable effect. 

The data are also insufficient to establish the period of pregnancy 
at which maternal impressions are most liable to cause mental defects 
in the child ; and additional difficulty is placed in our way here by the 
circumstance that the impressions are usually prolonged. It would seem 
most probable that the mind of the child would be most readily affected 
in the later months of pregnancy. "The permanent cerebral convolu- 
tions are formed from the seventh month onward." (Landois.) 

Bodily Defects. — Far more cases of bodily than of mental defect 
have been attributed to maternal impressions, and the reason for this 
is obvious. The bodily defects are apparent at the birth of the child ; 
the mental defects are obvious only at a later period, when the child's 
mind should have undergone development, and by that time the various 



Maternal Impressions. 295 

causes of anxiety or mental distress during pregnancy have probably 
been forgotten. 

As has been mentioned heretof ore, the doctrine of maternal impres- 
sions, so far as the production of bodily defects are concerned, has met 
with vigorous opposition. Some of those who have been the most 
strenuous in their opposition have, however, acknowledged that mal- 
formations may be caused by physical impressions, such as "unaccus- 
tomed agitation and fright." (Foerster.) 1 

Rockistansky, whose vast experience and sound judgment give 
weight to all his statements, says : "The question whether mental emo- 
tions do influence the development of the embryo, must be answered in 
the affirmative. Instances undoubtedly have occurred of such maternal 
impressions — fright more particularly, when violent — giving rise to 
malformations." 2 

He goes on to state that it is just conceivable that the connection 
may be accidental. He refers, also, to a fact with which all anatomists 
are familiar, that anomalies of the vascular system are more common 
than those of any other part of the body; but the heart and blood- 
vessels are so far shut in from direct observation that the influence of 
maternal impressions in the production of these anomalies has scarcely 
been noticed. Peacock, alone of all the writers on the subject, calls 
attention to the probable connection between impressions made upon 
the pregnant woman, and congenital defects of the heart. 

"One of the strongest evidences against maternal impressions on 
the child in utero, in the opinion of the opponents of the doctrine at 
least, is that all deformities are due to errors of development. Now 
there are two difficulties in the way of this objection. It presupposes 
that all defects which have been attributed to maternal impressions 
were 'errors of development/ or deformities in the common acceptance 
of the term, which is not the case. We shall see that in a considerable 
proportion of the cases which have been reported by reliable physicians, 
there was no error of development, but a mark or marks which evi- 
dently occurred late in pregnancy, when the development of the child 
was practically complete. But the fact that in a very large propor- 
tion — a large majority indeed — of the cases the defects were plainly 
due to errors in development, does not in the least militate against the 
doctrine of maternal impression, provided it can be shown that the 
impression was made at a period of pregnancy when the development 
of the deformed part of the body was not complete. It is not a ques- 
tion as to how maternal impressions produce deformities, but whether 
they actually do produce them. 

"The whole subject has to be considered from a number of differ- 
ent points before any definite conclusions can be reached; and it will 
be well to state before proceeding further what those different points 
are. They are as follows : — 

1 "Die Missbildungen des Menchen," p. 4, vol. 1. 

2 "Pathological Anatomy," vol. 7., p. 11. 



296 Maternal Impressions. 

"1. The period of pregnancy at which the impression was made. 
This is important in order to determine whether the impression was 
made at a time when an error in development was possible. 

"2. The similarity of the defect in the child to the object making 
the impression upon the mother. 

"3. Whether or not it is necessary for the woman to be conscious 
of the impression, for the defect to result. 

"4. The value of a statement of the character of the impression 
made before the birth of the child, and the proportion of cases in which 
such antepartum statements have been made. 

£ "5. The channels by which the impressions have been received by 
the mother. 

"6. The duration of the impression necessary to produce the 
effect. 

"7. The character of the impressions which are most liable to 
produce results. 

"8. A brief consideration of the objections which have been urged 
against the doctrine of maternal impressions. 

"9. The practical deductions to be drawn from a consideration of 
the subject." 

For convenience we shall tabulate a few out of the ninety case^ 
reported in Keating's "Cyclopedia of Diseases of Children," which 
is considered worthy of credence. 

The table will show : (1) The name of the reporter ; (2) the journal 
or work in which the report may be found ; ( 3 ) the period of pregnancy 
at which the impression was made; (4) the cause or nature of the 
impression ; and ( 5 ) the nature of the defect in the child. 

1. Brydon. British Medical Journal, July 17, 1886. Period 
of pregnancy, two months. Mother stated before knowing the nature 
of the defect, that she had seen a picture of a child without a neck. 
The child had no neck. 

2. A. M. Brown. British Medical Journal, February 20, 1886. 
Period not stated. The mother had her ears pierced, and was much 
disturbed afterward for fear of effect on the child. Child born with 
holes in the lobules of the ears. 

3. T. Graham. British Medical Journal, March 6, 1886. 
Period not stated. The mother was frightened by a rat. Three fin- 
gers of right hand webbed ; nails like claws. 

4. Brydon. British Medical Journal, April 3, 1886. Mother 
dreamed her big toe was bitten off by a rat. Child born with one toe 
missing. 

5. Barrett. British Medical Journal, April 10, 1886. Period 
from time of marriage. The milkman, whom the mother saw daily, 
had one finger amputated. Child had only four fingers on one hand. 

6. Addenbrooke. British Medical Journal, May 13, 1871. 
Period five or six months. Woman saw her mother suddenly stricken 



Maternal Impressions. 297 

with paralysis on one side. Child born with facial paralysis on one 
side. 

7. Bolton. St. Louis Medical and Surgical Journal, October, 
1881. Period four months. Woman saw an albino at a circus. Child 
born with a patch of white hair on its head. 

8. Bolton. St* Louis Medical and Surgical Journal, October, 
1881. Period three months. Mother saw a man with a harelip, and 
was much impressed (previous child normal). Child had harelip. 

9. Bolton. St. Louis Medical and Surgical Journal, October, 

1881. Period three months. Young opossum thrown in woman's 
lap; she was much startled. K"o expectation of defect. Child had 
ears like an opossum. 

10. Fairbrother. St. Louis Medical and Surgical Journal, 
August, 1881. Period three months. Mother saw a man with two 
fingers of right hand amputated. Child had only three fingers on the 
right hand. 

11. Furnam. St. Louis Medical and Surgical Journal, May 5, 
1880. Period two or three months. Mother frightened by a jackass. 
Child had head and ears like a jackass. 

12. Furnam. St. Louis Medical and Surgical Journal, May 5, 
1880. Period two months. Mother saw a terrapin killed ; was greatly 
shocked. Child had claws like a terrapin. 

13. Trenholme (quoted by Furnam). St. Louis Medical and 
Surgical Journal, May 5, 1880. Period not stated. Mother saw a 
man with both legs amputated; was greatly impressed. Child born 
with both legs absent. 

14. Maughs. St. Louis Medical and Surgical Journal, Decem- 
ber, 1882. Period four months. Woman dreamed her child would 
be hermaphrodite; so informed her husband at the time. Child was 
hermaphrodite; form of sexual defect not mentioned. 

15. Scott. St. Louis Medical and Surgical Journal, December, 

1882. Period two months. Mother frightened by the sight of the 
frog-faced woman. Child like the frog-faced woman. 

16. Atkinson. Philadelphia Medical Times, August 8, 1874. 
Period not stated. Mother frightened by lightning, and grasped the 
left arm just below the elbow. Left arm ended with rudimentary 
fingers just below the elbow. 

17. W. T. Taylor. Philadelphia Medical Times, February 11, 
1882. Woman visited her mother, who had cancer between the eyes; 
was greatly distressed. Child born with large nsevus between the eyes. 

18. D. W. Prentiss. Philadelphia Medical Times. Early 
period. Woman saw friend with large nsevus on the face; mother 
slapped herself on right buttock, and said if child was marked, it would 
be there. Child born with large nsevus on right buttock. 

19. W. T. Taylor. Philadelphia Medical Times, November 25, 
1876. During pregnancy, mother saw beggar with fingers of one hand 
missing; greatly impressed. Child had no fingers on the right hand. 



298 Maternal Impressions. 

20. W. T. Taylor. Philadelphia Medical Times, November 25, 
1876. Early period. Mother looked with "unaccountable delight" 
on her father-in-law's bald head. Child had a bald spot on its head. 

21. Hammond. Quarterly Journal Psychological Medicine, Jan- 
uary, 1868. Period two months. Woman saw her husband with a 
severe wound in his face; greatly shocked. Scar on face, correspond- 
ing in site to father's injury. 

22. Doty. Medical and Surgical Reporter, July 2, 1881. Four 
months. Woman attacked by a ram and greatly alarmed. Long head 
covered with black wool, which extended down the back of the neck 
and on the arms ; large round eyes ; two large front incisor teeth ; cry, 
bleating. 

23. Hey wood Smith. Medical and Surgical Reporter, May, 
1881. Three months. Mother frightened by monkey. Girl with a 
face singularly like a monkey's. 

24. W. L. Allee. Philadelphia Medical Times, August 8, 1874. 
Early period. Mother saw a man with a harelip. Child harelipped. 

25. Wright. American Journal Obstetrics, January 8, 1878. 
Seven weeks. Mother visited brother, in jail for serious crime. Saw 
prisoner brought in with manacles on hands and feet. Greatly shocked 
and impressed. Child born at five months ; harelip ; fibrous cord con- 
necting one hand with the other, and similar cord connecting the feet. 

26. Storer. American Journal Medical Science. Beginning. 
Saw a hen's leg knocked off with a stone. Greatly excited about it. 
One foot missing. 

27. Adams. American Journal Medical Science. Not stated. 
Woman dressed stump of amputated arm for her brother. One arm 
absent. 

28. Rawlings. Medical and Surgical Reporter. Beginning. 
Woman impressed by sight of a man with one leg. Leg missing from 
the middle of the thigh. 

29. B. Johnston. British Medical Journal, March 28, 1885. 
Woman saw the "two-headed nightingale," and fainted at the sight. 
Child united from neck to hip in front. 

30. Wilson. Obstetric Journal of Great Britain, June 15, 1880. 
Last few days of pregnancy. Woman received burns upon her hands. 
Child born with fresh-looking blebs upon its hand, corresponding in 
position to the mother's burns. 

31. Br ay ton Ball. Gynaecological Transactions, 1886. Two or 
three months. Woman saw a child with a large protruding tongue; 
impression strong. Child had a large protruding tongue from its 
mouth. 

32. Purefoy. Medical and Surgical Reporter, May 31, 1881. 
Woman attempted to raise by hand a calf, of which the right ear, right 
eye, and both forelegs were absent. Child had no right ear, no right 
eye, orbit indicated by slight depression; arm and forearm on right 
side absent, but there was an abortive hand attached to the scapula. 



Maternal Impressions. 299 

Roth quotes Meckel with respect to bodily defects brought about 
by maternal impressions, to the effect that "it is impossible that such 
casual connection could exist later than the first month of intra-uterine 
life." And Both himself, who is a pronounced believer in the power 
of maternal impressions, says the time they are most probably effective 
is during the first three months of pregnancy, or more exactly, from the 
second to the third month ; the plates come closer to each other, so that 
a separation at that time would scarcely be possible. 

With respect to special forms of deformity or defective develop- 
ment, which we are considering just now, — harelip and cleft palate, — 
we are told by embryologists that the superior maxillary process of the 
first branchial arch come together during the first eight or ten weeks of 
foetal life, and at the ninth week or soon afterward, the hard palate is 
closed, and on it rests the septum of the nose. 

The table shows that in the main the maternal impressions which 
produced, or which were supposed to have produced, these deformities, 
occurred at this very period. 

A woman seven months pregnant went to the door to answer a 
knock; she was shocked to see a man who could not speak, and from 
whose windpipe projected a tracheotomy-tube. Two months afterward 
the child was born with a tracheal cyst, and fistulous opening leading 
into it. It seems scarcely possible that there could have been any 
connections between the impressions and the defects in this instance, on 
account of the evident error of development to which the defect was 
due, and the late stage of pregnancy at which the impression was made. 

Is it necessary for the mother to be conscious of an impression, 
and to expect a defect, for such a result to ensue ? It is a singular fact, 
about which there can be no doubt, that it is not necessary for a mother 
to expect a defect in the child for such a defect to occur, whether this 
defect be mental or bodily. For example, in the case reported by Pure- 
foy, the woman does not seem to have expected that her child would 
present defects similar to those of the calf which she attempted to rear 
by hand, and which was, of course, so often before her eyes and in her 
thoughts. 

Of what value is a statement made by the mother before the child is 
born, as to the impressions, and the character of the defect which she an- 
ticipates ? In not a few instances the mother has stated before the birth 
of the child what the impressions were, and what she believed would 
be the nature of the defect in the child. For example, in Daley's case : 
A woman during the first three months of her pregnancy lived in a 
house which was infested with rats ; she was greatly annoyed by them, 
and at the birth of the child, before she knew of any defect, she asked if 
it was like a rat. The child had no neck and no face, but a long 
snout projecting from between the shoulders and in a line with the 
body. In two cases, also, and where the impression was due to a dream, 
the nature of the impression was closely and distinctly stated, months 
before the birth of the child, and in each instance the defects corre- 



300 Maternal Impressions. 

sponded thereto in a most remarkable manner. Evidence of this sort 
should be carefully weighed before acceptance, unless the defect corre- 
sponds very closely with the impression; for it is a fact that many 
women expect defects in their children, and often have very definite 
conceptions as to what those defects will be, and yet at birth the chil- 
dren are normally developed in all respects, and are free from any 
"marks" whatever. 

THROUGH WHAT CHANNELS ARE IMPRESSIONS MADE UPON THE MOTHER ? 

The channel through which impressions are usually received by 
the mother is that of sight ; but it is difficult to say how much is due to 
the simple sight of the object, and how much to the emotional disturb- 
ance caused by viewing it. It is very probable that the latter is really 
the effective cause ; for in some instances the effect has been caused in 
other ways, and yet the result has been the same. For example, in three 
cases the impression was caused by a dream. In another case a woman 
had her hand violently pressed by her husband's elbow, the pain being 
so great that she finally fainted. In this case the impression was 
evidently caused by violent pain. 

WHAT DURATION OF THE IMPRESSION IS NECESSARY TO PRODUCE A 

RESULT \ 

There seems to be no definite rule on this point, nor is it by any 
means easy to arrive at a conclusion with regard to it. 

In a number of cases the shock was sudden ; but the mental impres- 
sion resulting therefrom was far more enduring, and it is impossible to 
say whether the defect would have resulted if there had been nothing 
to induce it but the sudden and fleeting shock. 

WHAT CHARACTER OF IMPRESSION IS MOST LIABLE TO PRODUCE DEFECTS % 

In the vast majority of cases the impression is due to some emo- 
tional disturbance, and in nearly all the cases included in the table the 
emotion was of an unpleasant character. Fright and mental impres- 
sion resulting therefrom, would seem to be by far the most common of 
all causes. Physical suffering must have caused it in two cases. It 
was pity, doubtless, that led the woman to attempt to rear a deformed 
calf by hand, resulting in the marking of her child. 

"Unaccountable delight" may be the cause, as in the case of the 
woman looking at the bald head of her father-in-law during her preg- 
nancy. It is singular, in view of the frequency with which defects are 
attributed by the general public to "maternal longings" for certain 
articles of diet, that so few cases of this character should have been 
reported by physicians. 

Abnormalities may occur without fright. 

Deformities generally occur before pregnancy is certain, or before 



Maternal Impressions. 301 

the mother is conscious that she is pregnant, as in case mentioned of the 
milkman having one finger amputated. 

Abnormalities may occur in animals. Furman has reported a case 
in point, which occurred in Anderson, Kentucky. There passed 
through the town a menagerie, with which was an elephant ; a sow preg- 
nant a short time saw this elephant, and one of her pigs, born some 
time afterward, had skin, trunk, and ears similar to those of an ele- 
phant. He states that a similar case had occurred in Shawneetown, 
Illinois. ~Now, unless we deny the facts, the conviction that the rela- 
tionship in these cases is that of cause and effect, seems almost irresist- 
ible. 

Several children of the same parents often present bodily abnor- 
malities. The writer knows a family who inherited harelip for three 
generations. Grandfather, father, and son were born harelipped. 

The fact that fright and emotional disturbances of other kinds are 
common in pregnant women, and deformities comparatively rare, is not 
a just ground for unbelief in the power of maternal impressions. It 
would be as unreasonable to say that scarlet fever is never conveyed 
by milk, because but few cases of the kind have been reported, as to 
say that maternal impressions never cause deformities, because such a 
connection can rarely be established. The fact that scarlet fever is 
sometimes conveyed in milk was well established long before the nature 
of the disease was definitely understood, and it was not rejected because 
no explanation could be given ; and shall the fact that impressions some- 
times produce deformities be rejected because we can not understand 
how they act ? 

There remains, finally, the practical part of this whole subject yet 
to be considered. It is advisable that a woman should be guarded 
from strong emotional disturbances of every kind during her preg- 
nancy, for fear of the effect upon her unborn child. With the light 
before us, there can, I think, be but one answer to this question. Few 
as are the instances, relatively speaking, in which deformities are 
traceable to maternal impressions, they are yet sufficiently numerous, 
and sufficiently distressing, to necessitate care on the part of every preg- 
nant woman ; and I can not but think that it is the duty of every physi- 
cian to warn his pregnant patients of the necessity for avoiding power- 
ful emotions of every kind, and especially those which are of a distress- 
ing character. 

With the facts before us, the following conclusions with regard 
to "maternal impressions" seem to me to be warranted : — 

1. Impressions made upon a pregnant woman are capable of caus- 
ing mental and bodily defects in her child. 

2. Neither mental nor bodily defects are often, comparatively 
speaking, attributed to mental impressions. 

3. The defects attributable to mental impressions may be either 
errors of development or "marks," which are apparently due to cir- 
culatory or inflammatory disturbances. 



302 Maternal Impressions. 

4. The defects due to errors of development have, as a rule, been 
attributed to impressions made at a period of pregnancy when such 
errors of development are known to> occur. 

5. The other defects (marks, etc.) have, as a rule, been attributed 
to impressions made at a later stage of pregnancy, when circulatory 
and inflammatory disturbances would be most reasonably expected. 

6. In a very large proportion of the cases, there is a striking sim- 
ilarity between the object causing the impression and the defects in the 
child. 

7. It is not necessary for the woman to be conscious of the impres- 
sion, or to expect a defect, for such a defect to occur. 

8. In a very considerable proportion of cases, the woman has 
stated the nature of the impression, and of the anticipated defect, before 
the birth of the child. 

9. The impressions are generally due to emotional disturbances 
which are nearly always of an unpleasant character, but physical pain 
is capable of producing impressions which may induce defects. 

10. An impression of considerable violence may produce an 
impression in a short time, even a few hours, but, as a general rule, 
the duration is probably much longer than this. 

11. Maternal impressions are capable of producing defects in the 
lower animals. 

12. Defects traceable to maternal impressions are sufficiently 
numerous and sufficiently serious in character to necessitate the avoid- 
ance by any pregnant woman of all violent disturbances, especially 
those of an unpleasant character. 

I will give a short sketch of the most important pathological con- 
ditions affecting foetal life. 

The various conditions that unfavorably influence the foetus in 
utero will be considered sufficiently for the women to have a clear under- 
standing of this very important subject, 

The catalogue of foetal diseases referable to maternal influences is 
a long one. Nervous disturbances, high temperature, defective nutri- 
tion, disease of the womb and of its adnexa and lining membranes, 
alteration in the blood pressure, the presence in the blood of soluble 
poisons, or that subtle influence which we call heredity, — any of 
these may be accountable for disease or foetal death. 

THE INFLUENCE UPON THE FOETUS OF NERVOUS DISTURBANCE IN THE 

MOTHER, 

We will quote from Barton Cooke Hirst, M. D. : — 
"No one has demonstrated a direct nervous connection between 
mother and foetus, yet no one will deny the remarkable sympathy 
between the two. Mental peculiarities, acquired, perhaps, only dur- 
ing pregnancy, are not rarely stamped indelibly upon the foetus. The 
mother of Jesse Pomeroy, the well-known moral monstrosity, of New 



Maternal Impressions. 303 

England, took delight, while carrying this child in utero, in watching 
her husband, a butcher, ply his trade. The boy's irresistible inclina- 
tion to torture and slay may well have had its origin in its mother's 
perverted taste during her pregnancy. But more wonderful still is the 
occurrence of physical defects or peculiarities in the foetus, photo- 
graphic reproduction of objects that have produced a strong impres- 
sion upon the mother during pregnancy. I had occasion once to 
administer many hypodermic injections to a woman in the early months 
of gestation, producing in several instances small abscesses which left 
conspicuous scars. The child was born with spots upon it identical in 
appearance and situation with those upon its mother's arm. Still 
more extraordinary examples of maternal impressions have been seen 
by others. The fatal effect, in some instances, upon the foetus, of strong 
emotions in the mother, have seemed to me explicable in the light of 
recent discoveries as to the formation of leucomaines and ptomaines. 
Perhaps the powerful nervous disturbance acts upon the blood like an 
electrical current upon a chemical solution, altering its composition. It 
would be difficult to explain by this theory, however, cases of congenital 
idiocy which may be traced to emotions of fear, anger, or disgust dur- 
ing pregnancy. I have been recently told of a remarkable case of this 
kind. A lady was obliged to pass the night with an intoxicated bride- 
groom ; conception occurred, and the child became an idiot. Three 
subsequent children were also mentally defective, although there was 
no taint of insanity on either side of the house. The impression of 
deep disgust experienced at the first conception exerted an influence on 
the development of the subsequent children. A great fright during 
pregnancy, if it does not kill the child outright, may much diminish 
its mental capacity. Down 1 says that he can refer to a number of cases 
of f eeble-mindedness which were the outcome of the siege of Lucknow, 
and the same author refers to an incident of the siege of London (1795). 
In addition to a violent cannonading, the arsenal blew up with a terrific 
explosion, which few could hear with unshaken nerves. Of ninety-two 
children born in that district within a few months afterward, eight 
become idiots. We must frankly admit that an explanation of sus- 
ceptibility displayed by the foetus to violent impressions upon the mater- 
nal nervous system, is beyond our power ; we are obliged, notwithstand- 
ing, to allow that the fact is as well established as anv in medicine." 



'Mental Affections of Childhood and Youth, ; ' London, 1887. 



CHAPTEE XVI . 
DISEASES OF THE FOETUS. 

DEFECTIVE NUTRITION. 

Defective nutrition in the mother, with its consequent anaemia, 
either is fatal to the foetus in utero, or else is accountable for the birth 
of puny, wretched children, who die early or drag through a sickly 
childhood. The causes of the maternal malnutrition are many. 
Among the more serious are chronic diseases, as cancer, phthisis, 
malaria, nephritis; 1 chronic poisoning, as by lead or tobacco ; inability 
to retain food, as in the vomiting of pregnancy ; inability to obtain food, 
a? during siege and famine. The "enfants du siege" of Paris were 
for some time distinguishable from the children born before and after 
them. The treatment of foetal ill health from maternal anaemia is, of 
course, to improve the mother's impoverished blood ; remove the cause 
of the trouble, if possible; administer iron; and prescribe moderate 
exercise in the open air, with perhaps change of climate, and the birth 
of a vigorous infant can sometimes be secured, which will perhaps 
contrast strongly with its predecessors, which were not treated in 
utero. 

DISEASES OF THE ENDOMETRIUM, THE WOMB, AND ITS ADNEXA. 

These need only be mentioned here, for their most frequent effect 
is the premature expulsion of the ovum. We have known, however, 
a great inflammatory thickening of the endometrium to exist throughout 
pregnancy, with the result, apparently, of diverting nutriment to itself 
which should have gone to the child, which was born a feeble creature, 
and lived only a short time. 

poison: the maternal blood. 

Any soluble substance absorbed into the maternal circulation may 
pass from mother to foetus, such as chloroform, ether, salicylate of 
sodium, benzoate of sodium, strychnine, morphine, quinine, corrosive 
sublimate, iodide of potassium, urea, the bile salts, soluble salts of 
lead, — these are all said to affect the foetus in overdoses. Bile salts are 
said to be the most pernicious in their action upon foetal health and life. 



X E. Cohn stated at a meeting of the Berlin Obstetrical Society that eighty-six per 
cent of the children from mothers with nephritis, would be born still or too feeble to 
survive long. 

(304) 



Diseases of the Foetus. 305 

HEREDITY. 

The foetus in utero may acquire from its mother certain tendencies 
to disease, which may be manifested only in after life. The most remark- 
able example of this is found in the transmission of hemophilia, through 
a female to her male offspring. A young woman with a violent attack 
of chorea in pregnancy, told her physician that her mother had been 
affected with the same disease while pregnant with herself. Nothing 
is more familiar in nature than the transmission of physical, mental, 
and moral peculiarities from parent to child; and this fact must be 
taken into account by all clinicians. The question as a whole, however, 
is too large for consideration here, and it must be passed by with the 
brief mention it has received. 

DISEASES OF THE FOETUS REFERABLE TO ABNORMAL CONDITIONS OF THE 

FATHER. 

"It sometimes happens that the spermatic particle, while capable of 
fertilizing the ovum, is unfit to perform its share in the work of build- 
ing up a healthy, well-developed foetus. If the father is too young or 
too old, the subject of some debilitating disease, a victim of poisoning, 
or a drunkard, his fertilizing element may produce an embryo that will 
die before maturity, or else be born at term a defective, unsound infant. 
As saturnism in the mother is disastrous to the foetus, so also a man 
saturated with lead seems almost incapable of procreating healthy chil-t 
dren. Of thirty-nine pregnancies in women whose husbands were suf- 
ferers from chronic lead poison, eleven ended in abortion, there was one 
still-birth, and only nine of the children survived early infancy. 1 Men 
afflicted with nephritis, diabetes, 2 phthisis, 3 or cancer, have been found, 
in some instances, unable to produce a foetus capable of normal growth, 
while their widows, subsequently married, have borne healthy children. 
Drunkenness in the father is not infrequently a cause of ill-development 
in the foetus. Matthew Dunkan 4 lias called attention recently to the 
evil influence upon the foetus of intoxication in parents." 

SYPHILIS. 

Definition. — (Etiology uncertain.) Vulgarly called "pox." The 
true venereal disease is syphilis.' The term "secondary" is applied to 
syphilis after the morbific matter has been absorbed and diffused 
through the system. The secondary symptoms are ulcers in the throat, 
blotches on the skin, pain in the bones, etc. 

Syphilis as a disease of foetal life is put in a separate section 
chiefly on account of its great importance and relative frequency. It is 



'Paul, loc. cit. 

2 Priestly, Lumleian Lectures on Intra-uterine Death, London, 1887. 

3 D'Outrepont, JSTeue Zeitschr. f Geburst., 1838, Bd. VI, S. 34. 

*Edin. Medical Journal, April, 1888. 

20 



306 Diseases of the Foetus. 

separated from the other infectious diseases because its manner of 
invading the embryo and foetus is peculiar. Kuge estimates that 
eighty-three per cent of premature births and still-births may be traced 
to syphilis in one or both of the parents. (Zeitschr. f. Geburst, 
Bd. 1.) 

If a woman is syphilitic, every ovum within the ovary is diseased, 
and if fertilized will contaminate the resulting embryo. On the other 
hand, each fertilizing element from a man with this disease, carries 
within itself the seed of the disorder, to infect the ovum which receives 
it, although the maternal organism, as a whole, may remain unaffected. 
Again, if the syphilitic poison is introduced into the body of a preg- 
nant woman previously healthy,^ the disease may be transmitted to 
the foetus in utero. This doctrine of modes in which an embryo may 
become tainted with syphilis has not yet met with general acceptance, 
although it can be supported by the strongest proofs. 'No one, of 
course, now denies the fact that a woman infected before or at the 
time of insemination will probably produce syphilitic offspring. That 
the disease can be transmitted to the foetus in utero, or that the ovum 
alone can be infected while the mother remains, for a time at least, free 
from the disease, are statements not so universally admitted. A prom- 
inent authority in this country says, in a recent edition of his work on 
obstetrics: "The syphilitic poison will not traverse the septa inter- 
vening between the foetal and maternal vascular system." Neuman, 1 
however, has seen this very thing occur in five out of twenty women 
who were infected with syphilis during pregnancy. In the Maternite 
at Bordeaux, 2 of twelve women who were infected with syphilis in the 
first four months of pregnancy, all gave birth to dead children. In 
those cases in which infection occurred from the fourth to the sixth 
month, about half the children were still-born, and in seven cases of 
infection during the last three months there were four still-births. A 
woman in the Philadelphia hospital who acquired a chancre in the third 
month of pregnancy, gave birth to a child, still-born, which had on it 
unmistakable evidence of syphilis. This can not excite much surprise, 
for it becomes every day more clear that syphilitic poison is "a partic- 
ulate and living virus," 3 and we shall presently offer ample evidence to 
prove that disease-breeding germs can pass from mother to foetus. 

Modern authorities — Tarnier, Echroeder, Charpentier, Priestly, 
and many others — assert their positive belief in the transmission of 
syphilitic virus to the ovum directly from a diseased man, without the 
previous infection of the woman. As the foetus grows, however, and 
the syphilitic poison develops with its growth, the mother sometimes 
becomes infected, in her turn, directly from the foetus, through the 
utero-placental septum. 4 

*Wien Med. Presse, XXIX, 1885. 

'•'Hirigoyen, abstract in New York Medical Record, April 12, 1887. 
3 J. Hutchinson, British Medical Journal, 1886, I, 279. 

4 See Tarnier, et Budin, op. cit.; Priestlv, loc. cit. J. Hutchinson, British Medical 
Journal, 1886, I, 239; Harvey, Foetus in Utero, 1886. 



Diseases of the Foetus. 307 

DIAGNOSIS OF FOETAL SYPHILIS. 

The infection of the foetus may be inferred with reasonable cer- 
tainty if either parent had acquired syphilis at a date not too remote 
from the procreation. There is no doubt but that the probability of 
syphilitic persons bearing diseased children, somewhat diminishes as 
the time wears on; but the limit of safety has not been discovered. 
Lomer tells of the production of a syphilitic infant ten years after the 
infection of the father, and Kassowitz records a latent syphilis of twelve 
years' duration. If active treatment has been pursued, however, four 
years should serve to eliminate the poison. If a woman should acquire 
a chance during pregnancy, the possibility of the disease attacking the 
foetus is occasionally found in those cases in which the ovum is infected 
by the spematic particle. The woman may remain perfectly healthy 
till the middle of pregnancy, when signs of secondary syphilis may 
appear, without the slightest trace anywhere of a primary sore. In 
such cases the poison of the disease has been transmitted from foetus to 
mother. Yery often the signs of foetal syphilis can be looked for only 
in the foetus itself, after its expulsion from the uterus, and much may 
depend upon a correct diagnosis. This is, however, not always easy 
to reach. The parent's history, from ignorance or design, may be 
entirely negative. The child may be born with no distinctive sign upon 
its body. If it is living, however, the coryza and characteristic erup- 
tions during the first few weeks usually point clearly enough to the 
hereditary taint. If the child is dead, the diagnosis can be more 
easily made, unless maceration has proceeded very far; even then, 
however, there is one sign that may be regarded as quite distinctive. 

In these cases of foetal death it is important to ascertain the cause 
of the misfortune, in order to prevent its occurrence in subsequent 
pregnancies. The bulbous eruptions on the skin, the condylomata and 
inflammation of the mucous membrane, the inflammation of the serous 
membranes, the gummatous and miliary deposits, and the morbid 
growths of connective tissue in the brain, lungs, pancreas, kidneys, 
liver, and spleen, and the coats of the intestines, and walls of the blood- 
vessels, along with a characteristic osteochondritis, should demonstrate 
the character of the disease. Wagner was the first to call attention to 
a curious condition of the dividing line between diaphysis and epiphysis 
of the long bones of a syphilitic infant. Instead of a sharp, regular, 
delicate line formed by the immediate apposition of cartilaginous to 
bony tissue, as in a healthy foetus, there may be seen in syphilitic cases 
a jagged, rather broad line of a yellow color separating bone from 
cartilage. A microscopic study of this portion of the bone shows that 
there has been a premature attempt at ossification, which has ended in 
fatty degeneration. Since Wagner first called attention to this impor- 
tant point in diagnosis, we have looked for this sign in every case of 



308 Diseases of the Foetus. 

unmistakable syphilis that occurred in the Philadelphia and Maternity 
Hospital, and never failed to find it, while in doubtful cases it proved 
a valuable aid to a correct diagnosis. 

Zweifel thus describes the progress of the disease : " There is formed, 
in a certain region of the cartilage, granular tissue, insufficiently sup- 
plied with blood-vessels, and ill nourished. There results necrosis of 
this tissue, with an attempt at exfoliation, and an accompanying sup- 
puration." According to Roge, 1 the liver of a healthy infant should 
constitute about one-thirteenth part of the body x weight. In syphilitic 
infants, however, this proportion is much exceeded, the liver forming 
^in extreme cases one-eighth of the total body weight. The spleen, too, 
is much enlarged in syphilis. This organ, which in a normal foetus 
at term should be in weight one-three-hundredth part of the whole body, 
often much exceeds its due proportion. Upon these three signs, the 
yellow line between epiphysis and diaphysis, the increased weight of 
the liver, and the increased weight of the spleen, which are all easily 
discovered, the diagnosis of syphilis may rest with reasonable certainty. 

Prognosis. — The chances for a syphilitic embryo reaching a 
healthy maturity are very slim. Charpentier found, in an analysis 
of six hundred and fifty-seven cases, that more than one-third of the 
pregnancies in syphilitic women ended in abortion, while a large pro- 
portion of the children born at term were dead. Add to this low vitality 
of syphilitic infants, the high mortality among them, and it will be 
found that, fortunately for the race, hereditary syphilis is not so com- 
mon as one might expect, if it is looked for in children of more than a 
year's growth. 

Treatment. — Treatment of foetal syphilis is best begun before the 
embryo is called into existence, by eradicating the disease from the 
parents. If only one is affected, treat that one. In case of doubt, 
both man and woman should be put on a long course of anti-syphilitic 
remedies. The direct treatment of the embryo or foetus, after concep- 
tion, while not so satisfactory, should not be neglected, if there is 
reason to believe it syphilitic. 

Both mercury in its soluble salts and iodide of potassium will pass 
into the foetal circulation, and may modify or entirely prevent the 
morbid processes characteristic of the disease. In most cases the 
placenta will be diseased, and the affected area for oxygenating the 
foetal blood much diminished; and in such cases, potassium chlorate 
does good, and has been recommended by Simpson, Barker, Penrose, 
and others, although it may be doubted if the explanation formerly 
offered would account for its favorable action, that is, that it increased 
the oxygenating power of the maternal blood. 

Infectious Diseases. — These affections are produced by the 
entrance into the body, and the development there, of some low form 
of life. This has been conclusively proven of many infectious diseases ; 
of the rest it may be surely inferred, although the exact nature of the 

a Loc. cit. 



Diseases of the Foetus. 309 

materies morbi has in some instances not yet been demonstrated. The 
only medium of communication with the outer world possible to the 
foetus is the maternal blood. 

Variola. — The occurrence of variola in ntero has long been a fact 
beyond dispute. The foetus, however, is not always affected, even though 
the mother has the disease badly; on the other hand, the mother may 
transmit the disease to the child in her womb, although she remains 
healthy ; or a light attack of varioloid in the mother may be associated 
with virulent smallpox in the foetus. 1 Again, it has been noted that of 
twins one or both may be affected. 

.Rubeola. — The transmission of measles from mother to foetus is a 
i-are occurrence, but is. not unknown. Thomas collected six cases for 
medical literature. 

Scarlatina. — There are a few well-authenticated cases with an 
unmistakable scarlatinous rash upon them, accompanied by fever, and 
followed by desquamation and albuminuria. Those reported by Leale 2 
and Saffin 3 are quite typical. 

Erysipelas. — Kaltenbach, Runge, and Stratz have reported cases 
that were in all probability erysipelas in utero. 

Malaria. — Many practitioners have reported cases of periodic 
exacerbation of temperature in the new-born, apparently due to malaria 
acquired during intra-uterine life. We had a case recently in which 
the temperature rose, in a new-born infant, on two successive after- 
noons to 103 degrees Fahrenheit, the fever being preceded by great 
uneasiness. Quinine administered to the mother in large doses 
promptly cured the child. 

Tuberculosis. — It is said, curiously enough, the transmission of 
tuberculosis to the foetus in utero is an exceedingly rare occurrence. 

Septicaemia. — The possibility of the transmission of septic 
micro-organisms from mother to foetus has been denied by many, and 
strongly affirmed by Konbassoff, Chambrelent, Pyle, Mars, Von Hoist, 
and others. 

Cholera. — It is doubtful whether it affects the foetus, nevertheless 
early abortion is the rule ; or, if the child is born alive, it survives only 
a few days. (Queirel.) 

Typhoid Fever. — The most serious effect of typhoid fever upon 
the foetus in pregnancy is usually a premature expulsion of the ovum. 
This occus in sixty-five per cent of the cases. 4 It would seem, however, 
that the disease can directly attack the foetus. 

Articular Rheumatism. — Cases are reported of articular rheu- 



J See Tarnier et Budin, op cit; Wolf, Virch. Arch., Ed. cr. 

2 Medical Neios, 1884, p. 636. 

*New York Med. Recovd, April 24, 1886. 

^Berlin Klin, Worchenschr., 1886, S. 389. 



310 Diseases of the Foetus. 

matism affecting the foetus. Pocock 1 and Schaffer 2 each describe such 
a case. In both instances a woman gave birth to a child presenting, in 
one case at once, and in the other at the end of three days, unmistakable 
signs of the same articular rheumatic disease. 

Yellow Fever. — Dr. Bemiss, 3 of New Orleans, says, "The preg- 
nant woman being attacked by yellow fever, and recovering without 
miscarriage, immunity from further attacks is conferred upon the off- 
spring contained in the womb during the attack." If this is true, it 
certainly seems that the foetus, too, must have been infected by the 
disease. 

1 Pneumonia. — Cases of pneumonia are reported not infrequently 
Rachitis. 4 — Intra-uterine rachitis is not common, but there is abun- 
dant evidence to prove that the disease may occur in utero. It is thought, 
most likely the nutrition of the mother is at fault ; and not only improper 
or insufficient food, but also other unfavorable conditions of life, as cold, 
dampness, lack of light and ventilation, play a part in the production 
of fcetal rachitis. In the more advanced degrees of the affection an 
inspection of the product of conception after its expulsion from the 
womb, can leave no doubt as to the true condition. A stunted growth, 
heavy joints, limbs bent in curves or angles, and abnormally short, a 
distended belly with a "pigeon-breast," the large, square head with 
gaping sutures and fontanels, and bowed spine, all point unmistakably 
to this curious disease of the bones. The diagnosis of the disease in 
the foetus during pregnancy is, of course, impossible; therefore, no 
treatment will be attempted. 

Anasarca. — This disease of the foetus usually determines its pre- 
mature expulsion, most often between the fourth and eighth months, 
and the infant, even though it reaches a viable period, is commonly born 
dead. Foetal anasarca has been attributed to dropsy in the mother, 
syphilis, and to obstruction of the umbilical vein. The serous infiltra- 
tion of the skin is often accompanied by collections of fluid in the 
abdominal and pleural cavities, and the placenta is often oedematous. 

Spontaneous Fracture in Utero. — A syphilitic osteochondritis 
results not uncommonly in a separation of epiphysis and diaphysis in 
the long bones, simulating fracture. Advanced rachitis in the foetus 
is undoubtedly the commonest cause of intra-uterine fracture occurring 
independently of violence during pregnancy and labor. 

LUXATION AND ANCHYLOSIS. 

These affections of the joints in foetal life are not common. Dis- 
locations have been found more frequently in females than in males, 

1 London Lancet, 1882, Vol. II, p. 804. 
^Berlin Klin, Worchenschr. , 1886, S. 79. 

3 See Heinrich Braun Arch. f. Klin. Chirurg., Bd. XXXIV, S. 668. 
4 See Tarnier et Budin, op. cit., p. 255; Schorlaw, Monatschr f. (Gebuttsh., Bd. 
XXX, S. 401). 



Diseases of the Foetus. 311 

and are more commonly seen in the lower than in the upper extremities. 
If in a breech presentation the presenting part is detained for a long 
time in the pelvic canal, there may be an apparent anchylosis of the 
hip and knee-joints for some time after birth, the limbs rigidly retain- 
ing the position they occupied during labor. 

PERFORATION OF THE INTESTINES. 

Paltauf 1 has reported five cases of deaths in the first few hours 
after birth, due to perforation of the large intestines and escape of 
meconium into the peritoneal cavity. 

FOETAL TRAUMATISM. 

In spite of a position which secures for it the greatest possible 
immunity from external violence, the foetus has been seriously and 
fatally injured. Gunshot, stab, or other perforating wounds of the 
abdomen in pregnant women, falls from a height, blows, and kicks, or a 
crushing force upon the mother's abdomen, have killed the child within 
her womb. The damage done the foetus by this indirect violence is 
manifold. 

DISEASES OF THE FOETAL APPENDAGES WHICH REACT INJURIOUSLY OR 
FATALLY UPON THE FOETUS ITSELF. 

The foetus is essentially a parasite, depending for its well-being 
upon the health of its host and the normal condition of the tissues that 
put it into communication with its source of oxygen and nourishment, — 
the maternal blood. Disease, therefore, of the placenta, cord, and 
membranes must exert a malign influence upon the health and growth, 
or even the life, of the product of conception. Degenerations of the 
placental villi ; apoplexies of the maternal capillary loops that surround 
the villi in early intra-uterine life ; thrombosis of the blood, which 
moves in sluggish current through the maternal lacunae ; retro-placental 
effusions, which separate a certain portion of the placenta from the 
uterine wall; syphilitic overgrowth of the placental deeidua, which 
crowds in upon the inter-villous blood spaces, must all abrogate the vital 
functions of the placenta to a greater or less degree, with the result 
either of destroying the foetus outright, or else half starving and strang- 
ling it, and thus producing at term a puny, wretchedly-developed infant. 
Even should the placenta be in a perfect condition to perform its part 
in the formation of the foetus, the umbilical cord may fail to convey 
the blood to and from the foetal body in a natural manner. The cir- 
culation in it may be obstructed by knots, although these by no means 
cut off the blood current. The cord may be compressed in other ways, 
wound tightly about some portion of the child's body, or caught between 
the child's limbs. The caliber of the vessels may be diminished, also, 
by disease of their walls, by the great growth of connective tissue encir- 
cling both arteries and veins, that is commonly seen in syphilis ; or the 



l Virch. Arch., Bd. CXI, S. 461. 



312 Diseases of the Foetus. 

vessels may be almost occluded by a cellular infiltration of the cord 
substance, which is also, to my mind, a valuable sign of syphilis. The 
foetal circulation may be disturbed, if not entirely suspended, by 
hemorrhage from the vessels in the cord. The escape of blood, how- 
ever, into the cord substance is necessarily limited by the narrow area 
in which it is confined ; but in contrast to this is the bleeding that may 
follow rupture of the large branches of the umbilical vein spread out 
under the amnion on the foetal surface of the placenta. 

Cystic degeneration of the chorion, too, almost always involves the 
destruction of the embryo or foetus; yet cases have been reported of 
healthy, well-developed infants born at term, with rather extensive 
cystic disease of the chorion villi. Abnormalities of the amniotic secre- 
tion have a very decided influence upon the growth and well-being of 
the foetus. 

The amniotic fluids play an important part in the growth of the 
foetus, by distending the uterine cavity, allowing room for the free play 
of foetal movements, and preventing injurious pressure of the uterine 
walls; therefore, an insufficient quantity of fluid will prove a dis- 
advantage to the foetus. 

(The care of the child at and immediately after birth will be dis- 
cussed in the article on "Maternity and the New-born Infant.") 



CHAPTEE XVII. 

THE CAKE OF THE CHILD AT BIKTH, IN ABNOKMAL 

CONDITIONS. 

We do not always find the child at birth in a healthy condition. 
It is not always plump and red, with a cry whose pitch and volume at 
once suggests the lungs of a youthful stentor. Sometimes the child is 
in a condition of debility ; sometimes not only weak, but the victim of 
disease ; sometimes apparently dead, and sometimes really dead — still- 
born. 

The causes of these abnormal conditions are many and varied. 
They are the result of disease of the foetus during gestation, or the result 
of accidents of gestation and parturition. "The product of conception 
evolves, during gestation, from a cell to a matured foetus, and in this 
evolution, passes through changes and metamorphoses of the most 
extraordinary nature; and yet in healthy gestation, it accomplishes 
these changes and metamorphoses with a precision and exactness as 
mathematically accurate as the crystallization into well-known forms 
of a saline solution. Hence, it is evident that if the building material, 
out of which the future man is to be erected, be good, from it will be 
evolved a structure that will be correspondingly good. The evolution 
of a healthy, well-developed infant is, then, not a matter of chance or 
accident ; but it takes place as the result of laws as unerring and as 
precise as the laws of crystallization." (B. C. Hirsh, M. D.) 

Healthy men and healthy women, inheriting themselves good con- 
stitutions, and living healthy physical and moral lives, can not have 
any but healthy children. But, unfortunately, all men and women are 
not healthy; they have either inherited or acquired bad constitutions; 
and the inevitable consequence of it all is that when these imperfect 
men and imperfect women marry, if they have children, they must 
necessarily be more or less imperfect children. 

The study of prenatal diseases shows all sorts of abnormal evolu- 
tions in the embryo and foetus, and leads to a great variety of diseases, 
deformities, and monstrosities. They constantly cause the death of 
the product of conception during gestation, and hence, abortion, the 
great accident of gestation, is frequently due to them. 

"Over the threshold of life is written the declaration of nature's 
righteous and inexorable law, 'The fittest shall survive;' and this law, 
so just, so stern, so merciless in its unpitying exaction, is the law which 
governs, not only life's beginning, but life's progress and life's end." 

Man's intellect may enable him to elude the workings of this law 
for a time, but ultimately its majestic omnipotence triumphs; ulti- 
mately the fittest alone will survive. 

(313) 



314 The Care of the Child at Birth. 

Innumerable children die before birth, or at birth, not because our 
science or skill is valueless, but because nature's doom was pronounced 
at the moment of conception; and that wise and holy fiat by which 
alone a perfect race of men can be possible, — "The fittest shall survive," 
— that fiat proves their destruction. 

Sometimes children are born dead, sometimes apparently dead, 
and sometimes in a condition of asthenia or debility. 

DEBILITY IX THE NEW-BORN CHILD. 

Asthenia, or debility in the child at birth, is easily recognized. 
The infant is pale, at times blue. Its features are shriveled. If it is 
the victim of prenatal disease, it is often more or less emaciated ; though 
just born, it presents the appearance of age and decrepitude. The wel- 
come music of the child's first cry in these cases is looked for in vain. 
We notice the convulsive gasps, or hear low moans, and perhaps the 
gurglings of air, as it is painfully and laboriously drawn through the 
mucous accumulations of the larynx and trachea. The child breathes 
imperfectly, either because it is too feeble to expand its lungs, or 
because, being a premature child, these organs are not sufficiently 
developed ; hence its blood is not aerated ; hence it is blue ; hence it is 
cold; hence it can not cry. 

In the treatment of the new-born child in such conditions, we 
must carefully bear in mind the possible causes of the asthenia. 

Perhaps we are called upon most frequently to treat the debility 
in premature children, children born more or less before full time. 
We must be careful not to exhaust the feeble or fainting child by wash- 
ing it, etc. A weak child might die if subjected to manipulations most 
desirable for a strong and healthy one. The child may be too weak 
to rub with lard and wash. If possible, however, it is best to grease 
and wash it. I have had cases where they were freely rubbed, but very 
gently, with olive-oil, and wiped clean; then a bit of lint saturated 
with olive-oil was laid in the armpit, and also a bit of oiled lint in 
the groins. The face and mouth were washed, but not the head. The 
infant was then rolled up in warm, clean, carded cotton wool, and 
then in hot flannel, and laid in a warm crib or cradle, with a warm 
bottle in the crib to keep the child warm. Special care should be 
taken in regard to overheating — in having the bottles too hot. The 
child should be thus oiled twice a day, never exposing it to a cold 
atmosphere while the process of oiling is going on. The naval cord 
should be kept oiled and enveloped in a soft cloth. After a day or 
two, if the child seems stronger, you may give it a bath, as follows: 
The water should be as hot as can be used, from 110 degrees to 120 
degrees "Fahrenheit, or as hot as the back of your hand will bear, 
is a fair test for a proper heat, as many people have not thermometers 
at hand. Souie writers approve of using whisky and water baths. 
Use pure castile soap for cleansing the child. 



The Care of the Child at Birth. 315 

There are three elements, each of which is essential to the proper 
management of these feeble children. These essentials are : The removal 
of all obstructions to respiration, a very high external temperature, and 
the use of nourishment and internal stimuli. 

Obstructions to respiration in the mouth should be removed by 
wiping out the mouth. Those in the larynx and trachea are not so 
easily got rid of. An expedient at the time is to hold the child by the 
lower extremities, with its head down, and then shake it a little briskly, 
or spank it sharply on the nates; a sudden inspiration, followed by 
cough, may remove the whole trouble. Should such efforts fail, noth- 
ing is left but to wait in the hope, too often vain, that the child will 
ultimately acquire strength sufficient to take a full inspiration, and 
thus get rid of the obstruction. 

The second essential is a very high external temperature. It must 
be remembered that these feeble children breathe more or less imper- 
fectly; hence they do not inhale nearly enough oxygen to aerate the 
blood ; thus they must be cold and weak. As such children can not 
make heat for themselves, it must be supplied from without. Should 
the child's temperature fall much below normal, it will certainly die. 
Many feeble children die from this cause alone, who, if treated properly, 
might live. Each case requires careful and constant attention and 
watching, in order that the temperature may be increased or diminished, 
as may seem to be necessary. 

In many cases the temperature should be high. The body of 
the child should be kept at a temperature of not less than 98 degrees 
to 100 degrees Fahrenheit, and to secure this may demand the constant 
use of hot bottles and bags, etc. ; so also radiated heat from a hot fire 
or from an open fireplace. The surrounding atmosphere should be 
very hot, but not too dry. There must be moisture in the room, that 
is, if the heat is from a stove. A kettle of boiling water on the stove 
will serve to keep up the moisture in the room. If an open fireplace 
is used, a teakettle placed close to the fire will serve the purpose. The 
surrounding atmosphere being kept hot in the above manner, with hot 
bottles in the crib, the warm blood passes through the lungs, and the 
internal as well as the external temperature will be maintained. 

Cases are reported where a feeble, new-born child has been given 
up as dead, and left hopelessly in front of a very hot fire, and, after 
a very prolonged "toasting," it has been discovered to be alive, and has 
subsequently done well. 

The third essential in these cases is the use of nourishment and 
internal stimuli. The child is too feeble to take nourishment by suck- 
ing, and it should be administered by a mop or a teaspoon. It should 
be given in small quantities, a few teaspoonfuls at a time, very hot, 
but not hot enough to burn, and should be given frequently. Give 
hot milk mixture, and hot water. Some writers recommend spirits 
diluted. The writer prefers the hot milk in place of hot diluted spirits, 
and has found hot diluted milk the most useful. I have found a tea- 



316 The Care of the Child at Birth. 

spoonful of moderately strong black coffee with the hot milk to be 
stimulating enough. Formula, one heaping teaspoonful of pure coffee 
in a half teacup of boiling water; let it steep, not boil, on the back 
of a hot stove for ten minutes. This will serve the purpose of the 
whisky, and *there is no risk from overstimulating the brain, as with 
whisky or brandy. 

However, you may have to give hot whisky every ten to fifteen 
minutes. If so, dilute it one teaspoonful to six of water, sweeten, 
and give alternately with the hot milk, when the coffee seems not 
to agree when mixed with the milk. As soon as possible, the child is 
put to the mother's breast. We have had success in drawing milk 
from the mother's breast in a warm breast pump and feeding it to the 
child. By treating feeble children in this way, we often have the 
great satisfaction of saving lives otherwise doomed. The writer will add 
that to keep up the constant use of coffee is not approved of; as soon 
as the child is stronger, the coffee stimulus can be gradually removed. 
Nevertheless, in spite of all our efforts to save these cases, they often 
die. They gradually become colder and colder ; their faces and hands 
bluer and bluer; their respiration more and more gasping and feeble, 
until it finally ceases. In such cases all treatment proves to be useless. 

THE NEW-BORN CHILD APPARENTLY DEAD. 

Children are born not merely in a condition of asthenia, but 
in a state of apparent death, which speedily becomes real death unless 
proper means are used to prevent it, and often in spite of all remedies. 
We find children born in this condition of apparent death presenting 
very different appearances. Sometimes the face and upper part of the 
body are red; sometimes they are marked with bluish spots, and swol- 
len; the eyes are prominent and injected. Again, the child may be 
pale, and may exhibit marked evidence of profound prostration. 
Some writers speak of these varied appearances being produced by dif- 
ferent lesions, as "apoplexy and syncope" of the new-born; others as 
the "congestive and simple asphyxia of the child;" others reject these 
terms as very imperfectly designating 'the pathological conditions they 
are meant to describe. It matters not by what name we call them, 
just so we can give the necessarf treatment at the time, and save 
the child. 

In the so-called apoplectic conditions, or the condition of con- 
gestive asphyxia, we find the surface swollen, the face red or bluish 
or spotted. The child lies apparently dead, makes no effort at inspira- 
tion, and makes no movement. The heart may or may not pulsate. 

The causes which it is said may occasion these phenomena are 
either asphyxia or direct compression of the cervical vessels of the 
child. 

Asphyxia produces them in the new-born child, just as asphyxia 
produces similar conditions in the breathing child or in the adult. 



The Care of the Child at Birth. 317 

The blood is not aerated, congestion of the brain and kings follows, 
and paralysis of the cerebral centers results. Anything occasioning 
asphyxia, either during labor or after delivery, may be considered as 
a cause of the apoplectic state of the child. 

Compression of the cord during labor, twisting of the cord, pre- 
mature separation of the placenta, etc., in other words, anything sus- 
pending the foeto-placental circulation before delivery, will produce 
asphyxia as surely as plugging up the larynx of the breathing animal 
will produce it. So, too, after birth, any cause suspending respira- 
tion, as mucus or any other material in the larynx or trachea, may 
occasion it. 

The apoplectic condition may also be produced by any cause 
giving rise to direct compression of the cervical vessels. Hence, we 
meet it in face presentation, and in cases where the cord has been 
several times wrapped around the neck during labor. 

The child's brain is engorged with blood. This engorgement 
has produced pressure on the cerebral centers, which has paralyzed 
their action. Hence, when the child is born, its brain fails to respond 
to the stimuli which nature has provided to arouse it to the performance 
of the great function of respiration. The cold air striking on the 
cold, wet surface of the child, ordinarily a most powerful stimulus 
to respiratory action, is now incapable of waking up the oppressed 
and congested and paralyzed medulla oblongata. If we can not awaken 
the action of the medulla, the custodian of life's functions, the child 
must inevitably die. 

Bearing all this in mind, the treatment is evident. If the cere- 
bral paralysis is the result of mere congestion, in most instances the 
child, properly treated, will recover. If the paralysis is due to effusion 
of blood into the substance, or on the surface of the brain, it will 
die. There are no symptoms to enable us to determine whether the 
cerebral paralysis is the result of engorgement, or the result of cere- 
bral effusion, and therefore almost necessarily fatal; hence we treat 
all these cases alike. 

Remembering that congestion of the brain is the curable cause 
of paralysis, we must remove it by bleeding the child ; that is, we suffer 
to escape from the cord, one, two, or even three tablespoonfuls of blood. 
Should blood not flow from the cut cord, we may press and squeeze 
it from its insertion to the cut extremity. There is not much hope in 
the forlorn efforts of opening a vein. 

While the blood is flowing from the cord, sometimes the blue 
color disappears ; a rosy tint shows itself, first in the lips, then over the 
face, and finally over the body. The medulla acts, respiration is 
established, and the child is saved. 

The next remedy is the very hot bath — a bath of a temperature 
from 105 degrees to 120 degrees Fahrenheit. This very hot bath 
acts as a powerful revulsive, tending to relieve the overloaded brain, 
and to equalize the circulation, while at the same time it is a power- 



318 The Care of the Child at Birth. 

ful stimulus to the respiratory cerebral centre. After depletion, or 
without it, a basin 01 s a bucket of hot water may be brought to the. 
bed; and should the child not yet be separated from the placenta, 
because depletion from the cut cord has not been practised, the body 
of the infant may be plunged into the hot bath ; after immersion for 
from a few seconds to a half minute, the body may be brought to 
the surface, and water as cold as can be obtained, may be dashed sud- 
denly on the face and anterior surface of the thorax or chest wall. 
This expedient is a most powerful stimulus to respiratory action. 
The first contact of the cold water with the hot skin of the infant is 
frequently followed instantly by a sudden and full inspiration, and 
the treatment continued a few moments soon secures a satisfactory 
establishment of the respiratory process. 

Should bleeding and the hot bath fail, there may be tried, as a 
hope, artificial respiration. Though the next condition calls for this 
treatment, which we will describe, yet it may be practised for the 
present one of apoplexy or congestive asphyxia. 

There are several methods of artificial respiration practised on 
adults ; but for the apparently dead-born child, I am confident there is 
but one way, and that is to blow directly into the lungs of the child. First 
blow directly into its mouth by placing your mouth to the mouth of the 
child ; blow quick and hard. The air will force out any mucus that may 
be in the nose. Now press the nostrils together gently, to prevent 
the escape of the air from the nose; lean the head backward, or over 
the nurse's lap. The larynx must be pressed back against the anterior 
surface of the cervical vertebra to guard against the air entering the 
stomach. The practitioner, applying his or her mouth to the mouth 
of the child, blows directly into it. If a tube is at hand, it may be 
used, but the mouth is so much more expedient that it is to be pre- 
ferred. As soon as the lungs are sufficiently inflated to depress the 
diaphragm and raise the walls of the thorax, the blowing is discon- 
tinued, and the thorax and abdomen are to be gently pressed, in imi- 
tation of expiration. The blowing is then to be resumed, and the 
mechanical expiration to be repeated, as long as it is thought desirable. 
How long is it desirable to practise artificial respiration in this 
way on an asphyxiated child ? This question is not easily answered. 
We shall reply to it by giving the history of a case. "The wife of a 
young physician was confined with her first child, under the care 
of a celebrated professor of obstetrics. The labor was complicated 
and tedious. The patient, during labor and after delivery, was in 
great peril, demanding the entire attention of her medical attendant. 
The child, when born, was apparently dead. The old professor said 
to the young doctor, father of the child (the mother was unconscious, 
and therefore did not hear) : 'Doctor, cut the cord, and take the child 
away. It is dead, and your wife's condition claims my whole care.' 
The father separated the child, carried it into the next room, and 
placed it upon a bed. He then went back and again asked the pro- 



The Care of the Child at Birth. 319 

fessor if he was sure the child was dead, receiving again a positive 
opinion that the child was dead, and that all attemps to revive it would 
be useless. 

''The father returned to his dead baby, and, having nothing to do, 
in a wild, hysterical, utterly hopeless sort of way, began artificial 
respiration, after the manner I have described. Half an hour passed, 
with no results. The agonized father continued his efforts. An hour 
passed, but the infant seemed as hopelessly dead as it was before arti- 
ficial respiration was attempted. 

"The man's emotional paroxysm began to subside, and he began 
to realize that he was literally wasting his breath; still he did not 
desist. Suddenly he was startled by a slight, apparently spontaneous 
movement on the part of the child. With renewed energy he con- 
tinued his labors, and in a short time normal respiration took place, 
and to his extreme felicity, the child was saved. This happened thir- 
ty-five years ago. The great professor is dead ; the doctor, the child's 
father, is dead also ; but the child, called back to life by the hysterical 
blowings of an agonized father, hopelessly practised for the very long 
period of perhaps an hour and a half, is now a grave, mature man, 
still living, and the comfort and solace of the mother who, that day, so 
nearly died in giving him birth." (Penrose, M. D., LL. D.) 

Let this most interesting case answer the question, "How long shall 
artificial respiration be kept up in similar exigencies ?" 

Electricity and galvanism are said to be valuable agents for 
arousing the torpid nerve centers, and may, I have no doubt, in some 
cases prove efficient. They should be employed after other remedies 
have failed. 

SYNCOPE OF THE NEW-BORN CHILD, OR THE CONDITION OF SIMPEE 

ASPHYXIA. 

In simple asphyxia, or syncope, we do not notice the swollen and 
turgid face, etc., that characterizes the apoplectic condition that we have 
just studied. The child exhibits a mortal pallor, with all the evi- 
dences of profound debility. This syncope may be due to excessive 
debility of the child, or to some lesion of the cerebral centers ; hence 
we meet with it when the infant is diseased or premature, or has lost 
blood during labor. The paralyzing pressure is from the outside, and 
not from the inside of the head ; there is too little, not too much, blood 
in the child's brain. The treatment indicated in such cases is, first, 
preserve the connection between the child and the placenta' as long as 
the latter performs its respiratory functions. Second, endeavor to 
arouse the paralyzed cerebral centers to work. Third, stimulate the 
feeble and fainting child, generally and locally. We do not bleed 
these syncoptic children. They have too little, not too much, blood. 
We call for a basin of very hot water — temperature 120 degrees to 140 
degrees Fahrenheit, or as hot as you can bear the back of the hand in — 



320 The Care of the Child at Birth. 

and while the child is yet attached to the placenta, it is plunged into 
the water up to its neck. The heat acts generally and locally as a power- 
ful stimulant. Presently, as in the administration of the hot bath 
already described, the body is to be brought to the surface, and cold or 
iced water is to be dashed suddenly and forcibly on the face and the 
anterior surface of the thorax. This acts as the most powerful stimu- 
lant we have to arouse the benumbed cerebral centers to work. Keep 
up immersing the body in the hot water, and alternating these immer- 
sions with the dashing of cold water over the face and anterior surface 
of the thorax, as I have already directed, for some minutes. Often the 
§rst dash of cold water will cause an instant response. The child 
will give a spasmodic gasp, the lungs instantly fill, and the child's 
life is saved. If the child can swallow, it will be desirable, as soon 
as possible, to administer hot water and a little whisky every five or 
ten minutes, till the condition is relieved. (One teaspoonful of whisky 
in six teaspoonfuls of hot water, slightly sweetened.) 

When all pulsation has ceased in the cord, and we realize that 
the placenta may be separated from the child, the subsequent treat- 
ment must be something like that which I have suggested as proper for 
the asthenic infant; that is, the removal of all obstructions to respira- 
tion, and active external and internal stimulation. These are the cases 
for artificial respiration, to be practised as I have already described, 
for high external and internal temperature, and for the use of the gal- 
vanic battery. 

Children after tedious labors are sometimes born with their heads 
greatly compressed, and frequently much out of shape. It is not well 
to interfere in these cases. The proper treatment is to trust to nature, 
and not attempt to force or squeeze the head into shape. In a few 
days the natural elasticity of the structure will bring all the parts into 
harmonious relationship. 



CHAPTEE XVIII. 
IXJUKIES OF THE KEW-BOKX. 

Injuries received by the child during or in connection with labor, 
are classified as external and internal, the latter, of course, being, as 
a rule, the more serious. 

Injuries of the Head and Neck. — Erom the fact that in the vast 
majority of cases the cephalic pole of the foetal ovoid descends the 
birth-canal first; that the propelling force of labor drives this passive 
mass against resistances, overcoming them, or, on the other hand, 
moulding that mass, modifying its form, and sometimes even its struc- 
tures ; and from the additional fact that in these cases of cephalic pre- 
sentations, whether cranial or facial, the part is accessible to digital, 
manual, or instrumental means for facilitating delivery, it necessarily 
follows that injuries of the head during labor are much more frequent 
than those of any other part of the foetus. The great majority are not 
serious. They are superficial, and in a few days usually disappear, 
either with or without the employment of very simple therapeutic 
means. Some, however, leave permanent disability, or even may be so 
grave that death results. 

Caput-succedaneum ("Asuccedaneous Head"). — This is a term 
sometimes used for the tumefied scalp, which first presents in certain 
cases of labor. 

Sero-sanguineous Infiltration. — This is common, but not a constant 
phenomenon; for if the labor be rapid, and the resistance slight, the 
child may be born without this swelling. Nevertheless, such cases are 
exceptional, and the occurrence of caput-succedaneum is so common that 
it might be regarded as a physiological condition. 

This swelling may be round or oval, or in some cases, elongated, 
projecting almost like a pudding-shaped mass. In some cases it may 
be less than an inch in its longest diameter, supposing it to be oval, but 
in others two or three inches. The skin which covers it has changed 
in color, in consequence of the congestion. If the labor has been long, 
the surface of the tumor may be purplish or violet colored. So, too, in 
case of protracted parturition, the surface of the tumor may present 
phlyctenulae, or inflamed condition, which, when ruptured, leaves the 
derm exposed. 

In some instances, instead of there being simply an effusion of 
sero-sanguineous fluid in the connective tissues, rupture of blood- 
vessels has occurred, permitting hemorrhage, which, breaking this tis- 
sue, may be so considerable that a fluctuating tumor results. The rule 
is that the swellings do not occur as long as the membranes are ruptured ; 
21 (321) 



322 Injuries of the New-Born. 

but as observed by Tarnier, such rupture is not absolutely necessary. 
Schroeder and also Budin have met with tumors in some cases where 
the covering of the foetus was not only intact but extensible. 

The caput-succedaneum is usually formed during the dilatation 
of the os-uteri; but should there be subsequent delay in any part of 
the birth-canal — such delay being especially frequent at the vulvar 
orifice — a secondary caput is formed. If the pelvic inlet be narrowed, 
and the head pressed against the resisting bony ring by active uterine 
contractions, sero-sanguineous effusions soon occur, while the head 
remains above the superior strait. The seat of the caput-succedaneum 
indicates the position which the head occupied in a cranial presenta- 
tion ; also, it may be said, the position of the so-called caput-succedaneum 
in presentation of the pelvis and in that of the shoulder. The inap- 
propriateness of the term is obvious ; nevertheless the tumor designated 
by it has precisely the same origin, and the same essential character 
as in presentation of the vertex. 

The swelling in presentation of the pelvis occupies the hip, which 
is the lower, and this is usually, though not always, the anterior. "If 
in some cases the swelling upon the pelvic region is uniform, this is 
explained either by the slight obliquity of the presenting part, or its 
early correction, the two hips descending equally. Here, as elsewhere, 
the skin is of a more or less dark blue, and the tumor formed by tr: 
sero-sanguineous effusion variable in prominence and extent." If the 
child be a male, the scrotum may become doubled in size and black. 
Instances in which sloughing occurred have been recorded. 

In presentation of the shoulder, the sero-sanguineous tumor occu- 
pies the lower portion, but extends thence anteriorly or posteriorly 
upon the trunk, according as the latter may be inclined in front or 
behind. In case the elbow or hand descends first, then these become 
greatly swollen and discolored. 

Treatment. — If the skin is broken and the swelling is great, or 
if the effusion is of blood instead of serum, an erysipelas may arise 
from the former, or even gangrene may ensue, and in the other case 
phlegmonous inflammation or suppuration may occur. 

Following a facial presentation, the great swelling of the eyelids 
and the sub-conjunctival ecchymoses predispose to conjunctivitis. The 
lips and the tongue may be so swollen that the child can not nurse for 
several days, and it must therefore be fed. The broken surface result- 
ing from ruptured phlyctenular or possibly from the rough use of the 
finger nails, may be dusted with iodoform, or with boracic acid or 
acetanilid. If the swelling is very great, compresses dipped in a solu- 
tion of muriate of ammonia, or in a mixture of alcohol and water, or 
Pond's Extract may be applied. Should suppuration be threatened, 
warm fomentations and the application of a linseed poultice are indi- 
cated ; while if the distinct formation of pus is recognized, opening the 
abscess and washing out the cavity with a warm antiseptic solution 
would be proper. 



Injuries of the New-Born. 323 

Kephalohaematoma, or Thrombus Neonatorum. — By this is meant 
a soft, fluctuating tumor of the scalp caused by effusion of blood between 
the periosteum and the bone. It is usually situated upon one of the 
parietals, upon the right more frequently than upon the left, in some 
cases upon both ; it is rarely upon the frontal or occipital, or upon one 
of the temporals. The swelling, it is said, never transgresses a suture, 
though it may pass over and involve the adjoining bone, as in the case 
of Ducrest, in which the primary thrombus, occupying one of the 
parietals, passed over the intervening suture and under the other 
parietal. This tumor does not usually appear until from one to three 
days after birtli ; that is, when the caput-succedaneum is disappearing. 
It may be no larger than a pigeon's egg, or may have the size of a small 
apple. The skin-covering is not discolored, and thus a marked differ- 
ence exists between this tumor and that previously described ; it fluctu- 
ates, is not increased in size when the child is crying, and usually 
presents a distinct, bony margin around the base. Hemorrhage, either 
beneath or above the cranial aponeuroses, has been observed after the 
application of the forceps ; but these are diffuse, have no bony margin 
defining their extent, and generally are rapidly absorbed. The swelling 
disappears in some instances in two or three weeks, but more frequently 
it remains for a month or more. Rarely suppuration occurs, and this 
is liable to be followed by caries of the bone. If there should also be 
an internal as well as an external effusion of blood, the child perishes 
with convulsions. The cause of the affection is by no means clear. 
Those who, like Earle, Godson, and Desroizilles, accept the opinion that 
it affects the portion of the head where it is found constricted by the 
os-uteri, can give no explanation for its occurrence in pelvic presenta- 
tion, as has been the case in several instances. 

Treatment. — Since absorption of the effused blood takes place in 
the great majority of cases spontaneously, and as the child does not 
suffer in anywise from the tumor, active interference is not usually 
indicated. By some the application of a solution of muriate of am- 
monia, of tincture of iodine, of mercurial ointment, or compression by 
means of collodion, or a thin plate of metal, is advised. Desroizilles 
remarks that these different applications appear to accelerate the dis- 
appearance of the tumor, and can not cause any irritation or other acci- 
dents, when prudently made. The employment of setons, or of punc- 
tures, is not advised; although should an abscess form, opening it is 
indicated, and it is possible, too, if the collection of blood remains for 
some time without change, that aspiration, all antiseptic precautions 
being used, would be beneficial without any evil results. 

Wounds of the Scalp and of the Face. — Contused wounds of the 
face or of the scalp may be caused by the forceps, the accident depend- 
ing upon the form of instrument, or upon the mode in which it is used. 

The prophylaxis belongs to obstetrics, and therefore will not be 
considered here. Generally such wounds are quite superficial, and dis- 
appear in a few days. In their treatment, antiseptic powders, such 



324 Injuries of the New-B 



orn. 



as boracic acid, iodoform, aristol, etc., or ointments, as oxide of zinc, 
boracic-acid ointment, or fomentations may be used. Punctured or 
incised wounds of the scalp have usually been caused by the obstetrician 
mistaking the caput-succedaneum for the bag of water. Antiseptic 
applications are indicated. More or less serious injury to the eyes 
has sometimes been done by the finger of the accoucher, in case of 
presentation of the face. Such injury, as well as that spontaneously 
resulting more especially to the eyelids in this presentation, do not 
require special directions as to treatment. In rare instances, dangerous 
and even fatal consequences have followed sloughing of the scalp. 
This accident has been observed from spontaneous labor, and also has 
followed delivery with the forceps, one of the blades causing such 
severe pressure that gangrenous inflammation was the result. 

Facial Paralysis. — This accident, in most instances unilateral, has 
been followed by spontaneous delivery, but in the majority of cases it 
results from the use of the forceps, and is caused by pressure of one 
of the blades at the stylo-pastoid foramen, or a little in front of the lobe 
of the ear. The paralysis will not be observed when the infant is 
sleeping, but when awake and crying or attempting to nurse, it is quite 
apparent. It must be remembered that the complete absence of the 
mastoid apophysis, and the slight development of the auditory canal, 
favor compression of the facial nerve near its point of emergence. In 
some instances, only branches of the facial are compressed, and then 
the paralysis, instead of involving the entire half of the face, of course 
affects only the muscles to which these branches are distributed. In 
the majority of cases, recovery occurs spontaneously in from ten days 
to two weeks. In rare instances the paralysis becomes permanent, 
remaining unchanged, and therefore you can not make a positive state- 
ment as to recovery. It is generally advised not to employ any treat- 
ment until at least a month has passed without any improvement ; then 
electricity may be used, the induction current being first employed; 
and if the muscles fail to respond, the continuous current may be used. 
The Faradic current should be applied by letting the current pass 
through the operator's hand. The anode, or positive pole, is held in 
the left hand of the operator, with his right fingers, moistened with 
warm water, placed over the affected part of the infant, and a flat 
negative electrode covered with several thicknesses of surgeon's lint, 
placed over the "nuche" of the neck ; give the current gently from ten 
to fifteen minutes daily. The galvanic, if it has been resorted to, may 
be given by the same method, and ten milliamperes may be given for 
from ten to fifteen minutes daily, or every other day until the child 
recovers. It usually takes from six weeks to three months to effect 
a cure. 

INJURIES TO THE BONES OF THE HEAD DEPRESSIONS, FRACTURES, AND 

DISLOCATIONS. 

Depressions and indentations of the cranial bones are most fre- 
quently seen when delivery has been effected by the forceps, but they 
have also been observed after spontaneous expulsion of the child. 



Injuries of the New-Bom. 325 

Still more remarkable was the case reported by Matthew Duncan, in 
which a persistent impression was made by the finger of the accoucher, 
upon the right parietal bone, in an effort to produce anterior rota- 
tion, a funnel-shaped depression caused by pressure of the sacral 
promontory in a narrow pelvis. In most cases these depressions disap- 
pear in time, or notably diminish. 

Indentations, whether made by the forceps or occurring in spon- 
taneous labor, are frequently permanent, but are not usually the cause of 
any disability. 

Fracture of cranial bones has been observed following spontaneous 
and artificial, whether natural or instrumental, delivery. The parietal 
bones are those most frequently fractured, especially where the frac- 
ture occurs in unassisted labor ; but the frontal, the occipital, or one 
of the temporals may suffer this injury. The accident most frequently 
occurs in cases where there is a narrowing of the pelvic inlet, but it 
has also been observed when there was no pelvic deformity, and the 
child was normal in size ; and it has been suggested that untimely admin- 
istration of ergot may cause it, by producing violent and rapid expul- 
sion of the child. The posterior parietal bone is the one most usually 
fractured, when the head is either driven or dragged through the pel- 
vic inlet, narrowed in the conjugate diameter, the injury resulting from 
the resistance of the sacral promontory. 

Lomer 1 has recently reported twenty-seven cases of fracture 
of the skull from the use of forceps. In ten cases the fractures 
involved the frontal bone, four of these injuries over the orbit; five 
were of the parietal bones. The sagittal suture was ruptured six times, 
the lamboidal four times, and the occipital bone detached in Hve cases. 

If the fractures are associated with a rupture of the longitudinal 
sinus, a mortal hemorrhage ensues ; even, however, if there be no injury 
to large blood-vessels, that of smaller ones may give rise to bleeding of 
consequence ; or there may be injury done to the brain with that of the 
bone, so that these fractures should in no instance be regarded as triv- 
ial. Furthermore, such brain lesions may not always give immediate 
proof of their presence, but remote, it may be, in imperfect mental 
development. 

Treatment. — Little is to be said as to the treatment of these vari- 
ous injuries. Some of them are incompatible with life, the child per- 
ishing, it may be, from convulsions. Yet, on the other hand, an infant 
may survive some very serious injuries of the head. By gentle and 
careful manipulation in suitable cases, the normal shape of the head 
may be restored, fragments of displaced bones being brought in apposi- 
tion, and pressure upon the brain relieved. 

The only injury of neck which will be referred to is that 
involving the sternoclidomastoid. Torticollis of obstetric origin has 
been attributed to injury of this muscle by one of the blades of the 



1 Zeitschrift fur Geburtshulfe und Gynakologie. 



326 Injuries of the New-Born. 

forceps. This may explain the condition in some cases, bnt not in 
all; for children born head last have been affected. It seems more 
probable, however, that whether the forceps were nsed, or the delivery 
was by the breach, the labor was difficult, great traction being necessary, 
this traction causing an injury to the muscle, ruptures of some of its 
fibers, and a hsematoma results. But whatever the explanation, the 
characteristic condition present is a tumor situated just above the 
clavicle and in the muscle. As a rule, this tumor disappears spon- 
taneously, though several weeks may elapse before the event, and the 
function of the muscle is not impaired permanently. Active treatment 
is not indicated, though after the tumor has lost sensitiveness, some 
recommend weak tincture of iodine, or gentle friction first, then the 
iodine. The galvanic current may be used. Give ten milliamperes. 
Place the positive flat electrode, well covered with lint, over the tumor, 
pressing the electrode gently while the current is being applied, the 
negative electrode being placed somewhere down the spine to connect the 
current. This should be repeated three times a week until the tumor is 
absorbed. 

Intracranial Injuries. — These are liable to occur in different deliv- 
eries, whether these deliveries are spontaneous or either manual or 
instrumental. Meningeal hemorrhage is a common cause of the child 
perishing during labor. According to Cruveilhier, it is the cause of 
death in one-third of the cases of children dying at this period. Should 
the child be born alive, it may die from asphyxia soon after; but if 
the respiration is fairly established, the child may become comatose, 
have convulsions, usually unilateral, and die. 

Gower thinks that difficult labor has a great influence in causing 
cerebral palsy of the new-born. The essential characteristics of a cere- 
bral paralysis in the new-born, caused by labor, are, that there is no 
history of the disease or injury happening after birth, which can explain 
the condition, and that the paralysis gradually lessens. 

Treatment. — There is little to be said as to treatment of menin- 
geal hemorrhage. There is little to be hoped for from medicines, and, 
as remarked by Gower, drugs are useless unless to combat some of the 
effects of the disease. If associated with facial hemiplegia there is 
paralysis of the internal parts of the mouth, an internal injury of the 
nerves has occurred. Therapeutic means are without value. 

Injuries of the Trunk. — There will be omitted grave lesions of the 
spine, such as fractures of the vertebrae and injuries of the cord, rup- 
tures of the internal organs, whether of the chest or of the abdomen, 
and intra-abdominal as well as intrathoracic hemorrhage. In para- 
plegia in the new-born, in almost all cases death soon comes. 

Muscles of the trunk may suffer from such injury that a hsematoma, 
similar to that described as occurring in the sternoclidomastoid muscle, 
may be present. Its treatment is the same as that given for the affec- 
tion previously mentioned. 



Injuries of the New-Bom. 327 

Injuries of the Arms. — Fractures of the humerus are more fre- 
quent than all other fractures of the upper extremities, and. of the 
clavicle and scapula. 

The injury generally occurs in an effort to bring down an arm 
which has ascended in a head-last labor. The ascension is almost 
invariably the consequence of a hasty effort to extract the child; for 
if the expulsion be left to natural forces, the arms will remain folded 
upon the chest. Separation of the epiphysis of the head of the humerus 
from the diaphysis is an accident which may be overlooked, or thought 
to be a luxation, or a paralysis from an injury to the nerves. Kurt- 
ner 1 who has especially described this injury, states that its char- 
acteristic symptom is, that when the infant attempts to move, the 
humerus rotates inward. In its treatment he advises that the epiphy- 
sis, now rotating outward, be brought in contact with the diaphysis, 
and then the arm fixed by a bandage in a position somewhat outward 
and backward to the thorax. RTancrede advises, in the treatment of a 
fracture of the humerus, fixing the whole upper extremity in a straight 
position with a moulded splint. 

Paralysis of the arm has been observed in connection with a 
hematoma of the sternoclidomastoid injury of the deltoid muscle, com- 
pression of the axillary nerve, or from the employment of the finger 
or of the blunt-hook to effect extraction of the body when there is delay 
after the delivery of the head, and it has followed a shoulder-presenta- 
tion, the arm protruding, delivery being finally accomplished by podalic 
version, the want of power being independent of any cerebro-spinal 
lesion. Eecovery is the rule in these cases. 

Gower, in referring to the paralysis of the arm, remarks: "The 
nerves of the arms may be damaged in several ways. The injury may 
be associated with fracture of the humerus, and is then due either to 
the displacement of the broken ends of the bone, or to the force that 
caused the fracture. In such cases the distribution of the paralysis 
is irregular, and varies in each instance. In other cases, however, the 
injury is higher up to the roots of the nerves as they enter the brachial 
plexus. This injury is commonly produced by pressure at one spot, iu 
front of the edge of the forceps, which have pressed deeply here, and 
has effected the injury, leaving, at the same time, a mark on the skin. 
In other and more frequent cases the injury is produced by the point 
of a traction hook, or the tip of the bent finger, placed above the shoul- 
der for this purpose." 

Fracture of the clavicle is usually caused by direct pressure of 
one or two fingers upon the bone in the effort to deliver the head after 
pelvic presentation, or after podalic version. 

Treatment. — The injury is treated by fixing the arm, the forearm 
being flexed, by means of a roller bandage, to the chest, and then prop- 
erly supporting the member. The child should be, as far as possible, 
kept lying upon the back. The fracture is consolidated in six or seven 
days. 

^ber die Verletzungen der Extremitaten des Kindes. 



328 Injuries of_ the New-Bom. 

Injuries of the Lower Limbs. — A few instances of the fracture of 
the femur occurring in spontaneous labor have been reported ; but most 
frequently this injury has followed an effort to bring down the thigh 
in a case of pelvic presentation, where the presenting part was in the 
mother's pelvis, before pushing up that part so that room for move- 
ments of the thigh could be given, or from traction upon the thigh by 
means of the fillet or the blunt-hook. 

Dr. Nancrede advises that sheets of vulcanite should be used in 
the treatment of fractured femur. The material is softened in hot 
water and accurately moulded to the limb. "An anterior splint should 
t^e made which will extend well up over the abdomen, and a posterior 
splint which will reach from the buttock well below the knee, thus 
fulfilling the important indication of fixing the joints above and below 
the fracture. It requires only ten or twelve days for a firm union to 
occur." 

Dislocation of the hip in obstetric operations is exceedingly rare. 
Huge states that he has not found one in three hundred autopsies of 
the new-born. 

An unusual position of the lower limbs is observed for several 
days after labor in that variety of pelvic presentation described by some 
writers, in which the thighs are flexed upon the abdomen, and the legs 
extended upon the chest. The limbs for a time remain in the same 
attitude which they occupied during pregnancy and in labor, and it is in 
vain to attempt to place them in any other. 



CHAPTEK XIX. 
INFANT FEEDING; WEANING. 

The superiority of breast-feeding is so generally acknowledged 
that it may be said to have become a scientific statement. 

The great number of artificial foods nsed by physicians, accord- 
ing to the fashion of the day, only proves that bottle-feeding has not 
as yet arrived at that state of perfection where it can compete with 
breast-feeding. 

The feeding problem is one which is hedged about with many 
difficulties, on account of the great diversity of individual circumstances 
and idiosyncrasies. 

Certain infants, for instance, may thrive on peculiar mixtures not 
adapted to infants as a class. Many will not thrive on that food which 
nature has provided, and the well-being of an infant will depend much 
upon the circumstances by which it is surrounded, such as affluence or 
poverty, country or city life. 

In those cases where, for one reason or another, human milk is 
not available, the question of feeding is this, What may be given to 
take the place of nature's food ? In supplying a substitute we should 
copy in every possible way the physical and chemical characteristics 
of the food which is universally acknowledged to be the best. 

What is of the first importance is that we should recognize our 
ignorance, and, keeping our eyes opened to all possible scientific 
advancement, be ready to sweep aside preconceived ideas not resting 
upon established facts. 

Young animals at birth begin to receive their nourishment 
immediately, and a corresponding increase in their weight takes place 
from almost the first day of life. The human infant, in like manner, 
should begin nursing early, getting what it can from the breast until 
the full supply of milk has come. In this way it will not be so likely 
to have a large initial loss of weight to recover, by which it is often 
handicapped at the very beginning of its career, when there is most 
danger to be anticipated from a depression of its nutrition. In the 
early days of life, every day, every hour, is of the utmost importance ; 
and, provided it can be done without detriment to the condition of the 
mother, the sooner the child is put to the breast the better it will be. 
The continual increase in weight is of very great importance in the 
first year, as it is the chief index by which we note the progress of 
nutrition and judge concerning the desirability of continuing the 
food. An average gain of from twenty to thirty grammes, or about 
two-thirds of an ounce, a day through the rest of the year, makes a 

(329) 



330 



Infant Feeding; Weaning. 



successful line of nutrition, and may be used as a working basis for 
the management of the food. 

A healthy baby empties the breasts with easy and almost unin- 
terrupted sucking in about fifteen minutes. The quantity ingested is 
determined by various methods, such as by careful weighing before and 
after nursing, and by the determination of the actual capacity of the 
average stomach at different ages and with different weights. These 
results are of great practical importance, as we will state later on when 
we come to speak of artificial foods. 

The intervals of feeding constitute a very important factor in 
breast-feeding, where the quantity is regulated by the breast itself. 
According to Frolowski, 1 it can be represented by the ratio (that is, 
the activity of growth in the stomach's capacity) of one for the first 
week to two and one-half for the fourth week, and three and one-fifth 
for the eighth week, while it is only three and one-third for the twelfth 
week, three and four-sevenths for the sixteenth week, and three and 
three-fifths for the twentieth week. The first month is the most critical 
period for the infant's nutrition, as it is the time when the equilibrium 
of its metabolism is being established, and its chance for life is the 
least; hence, especial value should be attached to the series of careful 
investigations made at the Children's Hospital in St. Petersburg, by 
Ssnitkin, 2 to determine the amount of food which should be given 
during the first thirty days of life, and from which is deduced the rule, 
"The "greater the weight, the greater the gastric capacity." 

Ssnitkin' s general results show, also, that one one-hundredth of 
the initial weight should be taken as the figure with which to begin 
computation, and to this should be added one gram, or two-thirds of 
an ounce, for each day of life. The following table represents merely 
approximate average figures, which are the results of computations 
made by a number of observers in different parts of the world. 

TABLE I. 

The average initial weight of infants is about 6.6 to 8.8 pounds, 
or 3,000 to 4,000 grams. 

The average normal gain per day in the first five months is 20 to 30 
grams, or about two-thirds to one ounce. 

GENERAL RULES FOR FEEDING. 



Age. 


Interval | Nq in 24 HoURg . 
of Feeding, i 


Average at 
Each Feeding. 


Av'ge Amount 
in 24 Hours. 


1st week 


2 hours 


10 


1 ounce 


10 ounces 


I- week 


2J hours 


8 


1^ to 2 ounces 


12 to 16 ounces 


6 to 12 weeks, 

possibly to 
5th or 6th mo. 


I 3 hours 


6 


3 to 4 ounces 


18 to 24 ounces 


6 months 


3 hours 


6 


6 ounces 


36 ounces 


10 months 


3 hours 


5 


8 ounces 


40 ounces 



inaugural Diss., St. Petersburg, 1876. 
2 Eeitz, Physiologie Des Kindesalt, S. 40. 



Infant Feeding; Weaning. 



331 



It is necessary to consider the weight as well as the age in deter- 
mining the amount for each feeding in the individual infant, the rule 
being one one-hundredth of the initial weight, one gram for each day 
during the first month. 

The following illustration of the above rule serves as guide for 
especially difficult cases: — 



Initial Weight. 


Each Feeding. 


Early Days. 


15 Days. 


30 Days. 


3,000 grams 


30 grams 
(About 1 ounce) 


30-4-15 = 45 grams 
(About 1£ ounces) 


30-4-30=60 grams 
(About 2 ounces) 


4,500 grams 


45 grams 
(About 1| ounces) 


454-15=60 grams 
(About 2 ounces) 


454-80=:75 grams 
(About 2J ounces) 


6,000 grams 


60 grams 
(About 2 ounces) 


60-|-15=75 grams 
(About 2J ounces) 


60+30 = 90 grams 




(About 3 ounces) 



The only point in the feeding problem where artificial feeding 
seems to have the advantage of the breast is in the intervals of nursing, 
irregularity in nursing, frequent nursing, and too prolonged intervals, 
which often so disturb the quality of human breast milk as to transform 
a perfectly good milk into one entirely unfitted for the infant's power 
of digestion. But the element of intervals does not, of course, influ- 
ence the question of chemical composition in a properly-prepared arti- 
cle of food. Thus, too frequent nursing lessens the water and increases 
the total solids in human milk, making it resemble in a certain way 
condensed milk ; while too prolonged intervals result in such a decrease 
of the total solids as to render an otherwise good milk too watery, and 
unfit for purposes of nutrition, however well it may be digested. 
General rules for the feeding intervals should be enforced, such as 
are represented in table 1, in order that mothers should not interfere 
with the infant's digestion by nursing it too frequently, and thus giv- 
ing it too concentrated food, nor, by neglecting to feed it often enough, 
interfere with its nutrition by giving it a too largely diluted food. We 
must recognize two distinct elements in infant feeding, neither of 
which can with impunity be interfered with at the expense of the other, 
namely, digestion and nutrition. It is possible for the milk to be 
easily digested, and it is the equilibrium of these two elements which 
makes up a perfect infantile development. 

The younger the infant, the greater the metabolic activity, and 
hence the greater need for frequent feeding ; for nutriment is required, 
not only for repair and waste, but also for the rapid proportionate 
growth ; and we thus see that to regulate the intervals of feeding accord- 
ing to the age, as shown in table 1, becomes essential in successful 
feeding. 

The next question to be considered is the quality of the food which 



332 Infant Feeding; Weaning. 

is provided for the human infant. The analyses upon which most 
reliance is to be placed, are those of J. Konig, Forster, Meigs, Har- 
rington, and others; we give the approximate results: — 

TABLE II. 

Human Milk. 

Keaction slightly alkaline 

Specific gravity 1028-1034 

Water 87-88 

* Total solids 13-12 

Fat 3-4 

Albuminoids 1-2 

Sugar 7-0 

Ash 0-2 

Human milk has also been shown to be sterile by Escherick, who 
experimented with the milk of twenty-five healthy women, and found 
that, by keeping it in sterilized tubes, it remained unchanged for some 
weeks. 

The greatest variety of substances has been found in the milk, 
but no definite rule as to the amount of this elimination has yet been 
established, so that our knowledge of the existence of this process is 
valuable as a prophylactic against harm, rather than as a means of 
direct benefit to the infant in disease. The latter point will not be 
discussed here, except to draw attention to the fact that the medical 
treatment of infantile diseases through the breast milk is said to be 
exceedingly inexact. 

We must also recognize the clinical fact that it is not only when 
the milk is in poor condition that this elimination takes place, but that 
it may occur at any time during the nursing period in the breasts of 
women, who, so far as we can ascertain, are in a perfectly healthy con- 
dition. Thus, every practitioner has at times, doubtless, observed the 
laxative effect on the infant of such drugs as the compound licorice 
powder given to the mother. A case is on record where a baby vomited 
for weeks while taking the milk from the breast of a mother who was 
unusually strong and well, but was in the habit of drinking, daily, a 
considerable quantity of porter. The vomiting ceased at once, and did 
not return, after the porter was omitted. 

Both the secretion and the character of the milk are strongly 
influenced by the nervous system. This fact has become a matter of 
common clinical experience, but the exact nervous mechanism which 
controls it has not yet been fully worked out. The result, however, is 
recognized, that emotional mothers do not make good nurses. 

A healthy mother should nurse her child. The younger the 
infant, the more important the breast nursing, and certain of its func- 
canal is in a more active state of development, and certain of its func- 
tions are still unprepared for use in the early months of life. It is 



Infant Feeding; Weaning. 333 

very difficult to adapt an artificial food to the sensitive, growing, 
infantile digestive apparatus at this early age ; and this accounts, in a 
measure, for the rule that the younger the child, the greater the mor- 
tality. There is no doubt, however, that the mother's milk, in a con- 
siderable number of cases met with in the practise of physicians among 
civilized nations, appears to be entirely unfit for her offspring ; and it 
at times becomes a question of considerable importance as to whether 
the infant shall be withdrawn from its mother's breast, either tem- 
porarily or entirely. 

I am fully convinced that a large number of infants are deprived 
of their natural food, and placed on artificial foods, on insufficient 
grounds. We thus assist to keep up the high mortality figures ; and I 
believe that these figures will sensibly reduce when, in consequence of 
our taking a more enlightened view of the subject, we shall increase 
the number of infants who are fed from the breast during the first 
three or four months of life. 

A particular reason, among many, for waiting at least four or five 
months before beginning artificial feeding, is that after a rapid growth 
the stomach has, by the fifth or sixth month, become a more perfect 
receptacle as to both size and function. 

A simple illustration of weaning for insufficient reasons will be 
cited in the case of an infant three months old, which was brought to 
a physician to have its artificial food regulated. The history of the 
case was that its mother, a healthy primapara, about twenty-two years 
old, had nursed the infant for six weeks, during which time the infant 
was fretful, suffered much from colic, and never seemed satisfied. For 
these reasons, although there was a gain in weight, and the napkin 
showed a fairly good digestion, it was, by the advice of the attending 
physician, weaned at once. On careful inquiry it was found that this 
infant had been nursed almost continuously night and day, with inter- 
vals usually of only one hour, and it was evident that the frequent 
nursing had resulted in producing a concentrated milk, which the 
infant's gastro-intestinal canal was rebelling against ; and at six weeks 
of age the infant was deprived of its supply of breast milk in July, 
and placed upon an artificial food containing seventy-eight per cent of 
starch, simply because the important factor of intervals had not been 
thought of as a means of improving the milk and relieving the pain and 
apparent hunger. 

On the other hand, the general health of the mother should be care- 
fully investigated, as women suffering from constitutional syphilis or 
chronic consumption are manifestly unfit for nursing ; and at the same 
time we should be careful, unless decided symptoms of disease are 
present, not to set aside the milk of a delicate-looking woman until it 
has been analyzed. 

Instances frequently arise where such continued shocks are brought 
to bear upon the mother in her daily life, or where her own tempera- 



334 Infant Feeding; Weaning. 

merit is such an undisciplined one, that her milk, ordinarily good, 
becomes totally unfit for her infant, and at times acts as a direct poison, 
with most disastrous results; the welfare of the infant in such cases 
unquestionably demands a wet-nurse. 

A nursing mother should be made to understand that these varia- 
tions are liable to arise, however good her general health may be ; and 
that while she is simply fulfilling a duty demanded by nature from 
those who bear children, her duty, when she has once undertaken to 
nurse, is to avoid these variations as far as possible, by regulating her 
life to a normal lactation. And it comes within the province of her 
physician to explain this as he would any other branch of rational 
medicine ; for many a mother, by her course of life, renders her milk 
unfit for the proper alimentation of her infant, through ignorance of 
what seems to the physician but a simple dictation of common sense; 
and she will be only too thankful for advice on this subject. Instances 
are on record, which were observed by Yukowski, where seasons of 
fasting, with their accompanying excitement of the emotions, have 
had such an influence on the milk that the fat especially has been 
decreased to as low as 0.83, and many nursing infants became sick 
and gave evidence of imperfect nutrition. 

We must next consider the question of the variations of the milk 
which take place from natural causes, such as the return of menstru- 
ation. We must be guided by what seems best for the individual case. 

Infants are at times affected so seriously by the alteration in the 
constituents of the milk which occurs once in four weeks that their 
nutrition is markedly interfered with, and a change to a more stable 
food is indicated. Again, the only disturbance which arises is a tem- 
porary and slight digestive attack for a day or two, which apparently 
does not materially affect the infant, and makes us hesitate to run the 
risk of depriving it of a food on which it thrives during twenty-six days 
out of twenty-eight. We must also not be too hasty in concluding from 
a bad symptom in the infant that we should at once withdraw it per- 
manently from the breast, for the menses may appear once and not 
again for a number of months ; the infant's power of digestion in the 
meantime becomes so much more fully developed that it is unaffected 
by the catamenial milk. Even where the catamenia recur regularly, 
the disturbance which may have been marked at one period may for 
many reasons fail to recur at the next period, so that the question is 
reduced to whether the composition of the milk shows a recovery of the 
equilibrium of its constituents within a few 7 days, or remains affected 
to such a degree as to endanger the integrity of the infant's nutrition. 

My owm experience, so far as it goes, is in favor of allowing the 
infant to continue with the breast, unless it is decidedly contraindicated 
by circumstances such as have just been mentioned. 

I have seldom met with a case which could not without permanent 
injury be tided over the small amount of temporary digestive dusturb- 



Infant Feeding; Weaning. 335 

ance usually met with. Very frequently we have met with cases where 
it never produced any appreciable effect at all. The probable cause of 
these catamenial disturbances is the deficiency in fat in the milk and 
increase in its albuminoids; and following the general rule of dis- 
turbed mammary secretion, the condition is such as to interfere tem- 
porarily with both digestion and nutrition. 

It is a much more serious affair when the nursing mother becomes 
pregnant, for here the almost universal clinical experience is that the 
infant, for various reasons, can not continue to be fed by its mother, 
it being unusual for a woman to have sufficient vitality to nourish prop- 
erly her living child and the growing foetus. There is danger of reflex 
miscarriage from continual irritation of the mammary gland by nurs- 
ing. The writer believes that under almost all circumstances a preg- 
nant woman should wean her infant, since we know how to prepare 
food for infants. The mother does not run the risk of reflex miscar- 
riage, and thereby, in all probability, saves the life of the unborn ; the 
mothers health will remain in a normal condition, consequently her 
strength is maintained for the perfect development of the foetus. 

The food of the nursing woman is closely connected with the food 
which she provides for her infant. We have already spoken of the 
possibility of the elimination of various substances by the mammary 
gland, and we should impress upon nursing women the importance of a 
more carefully arranged regimen than when they are not nursing, and 
of a limited use of drugs. Saline cathartics may at times not only act 
unfavorably on the infant, but may very decidedly lessen the flow of 
milk, or even stay it altogether. Certain vegetables, such as sweet 
potatoes, and in some instances I have known beans and cabbage, 
cause colic in young infants. When the mother omitted these from 
her diet, the child never had any more colic. In some individuals the 
use of fish will cause discomfort to the infant. A plain mixed diet, 
with a moderate excess of fluids and albuminoids over what they are 
normally accustomed to, will, as a rule, give the best results. 

We should also be exceedingly 'careful about suddenly changing the 
customary diet of a healthy nursing woman on purely theoretical 
grounds. "The mistake was made for many years of keeping women 
on too low a diet in the early period of lactation, with a consequent 
delay in the establishment of a sufficiently nutritious milk supply, and 
a correspondingly-increased initial loss of weight in their infants. 
Where, however, we are especially likely to err is in permitting a 
healthy, hard-working wet-nurse, accustomed to a somewhat coarse but 
nutritious diet, on entering a refined home to adopt totally different 
habits of exercise and an unaccustomed diet, rather than endeavoring 
to have her continue in her natural mode of life. This sudden change 
of life frequently results in ill health to the nurse, with its accompany- 
ing deterioration in the quality of her milk, or at least in so changing 
its quality as to make it an unfit food for her foster-child." 

It not infrequently happens, especially among women of the upper 



336 Infant Feeding; Weaning. 

classes, and nursing women of all classes, when their general health 
is not in a perfectly normal condition, that the supply of milk is not 
sufficient to satisfy the infant, and the question arises whether the 
mother's milk shall be entirely given up, or whether it shall be supple- 
mented by some other food. In my own private practise I have found 
it advisable to assist the mother to nurse her infant during the early 
months of life. Where the artificial food is carefully regulated until 
the infant is making decided progress in its weight and general con- 
dition, this method of rearing infants is far superior to withdrawing 
the mother's milk, and feeding the child exclusively upon artificial food. 

It is a fact pretty widely acknowledged that the mother's milk, as 
a rule, is more likely to be suited to her infant's digestion than the 
milk of another woman. The reverse of this proposition has also been 
held true, that at times idiosyncrasies in the mother's milk will make 
it radically unfit for her infant. A wet-nurse is to be preferred to 
artificial food, and is most likely to give more satisfactory results. 

The question as to whether a wet-nurse shall be employed is, how- 
ever, one of serious importance, and must in each individual instance 
be decided by giving full weight to all the many circumstances which 
are involved in the case. It is the duty of the physician to fully 
explain that a good nurse is far superior to any artificial method of 
feeding, while the reverse of this statement must always be kept in view, 
that a poor nurse, whether from temperament or age or general health or 
quality of her milk, had* better be set aside where conditions are favor- 
able for a successful artificial feeding. It is considered better, perhaps, 
that the nurse's milk should correspond in age somewhat nearly to 
that of the infant she is to suckle, but a difference of some months will 
not be of vital importance in choosing a nurse. A feeble child will 
nurse more easily, and probably have better care, from a multipara 
than from a primapara. The preferable age of the nurse is between 
twenty and thirty years. Her other requisites are a condition of good 
health and a quiet temperament. It will save time, and perhaps 
trouble, if her milk be analyzed beforehand ; in fact, all the requisites 
should be inquired into. 

Quite a number of nursing women, especially those in the higher 
classes, find that at variable periods in the course of their year's lacta- 
tion, their milk begins to fail, and they are forced first to lessen the 
number of their nursings, and then to wean entirely. The time, then, 
when the infant should be weaned almost always settles itself without 
our intervention, at varying periods. The period of lactation, and the 
one which might be called physiologically normal, can, when the breast 
milk remains of good quality and quantity, be carried through the first 
year with benefit. We have certain guides which aid us in determining 
the proper time for beginning to wean. Physiologically, we are told 
that certain functions, such as that which converts starch into glucose, 
are but slightly developed in the early months of life, and that they are 
gradually established during the first year, but that, as a rule, they do 



Infant Feeding; Weaning. 337 

not exist in perfection, in such a condition that we can call upon them 
with impunity, until the last two or three months of the year. Another 
sign which aids us somewhat as an index by which we can judge of the 
progress of this functional development, is the appearance of the 
teeth, calling our attention to the fact that nature is preparing a means 
for the infant to digest and assimilate a different form of food from 
that which it has so far received by sucking, the presence of six or 
eight incisors usually, in the normally-developed infant, corresponding 
to the full development of the pancreatic secretion. 

Again, a most valuable index, which assures us that we need not be 
anxious to change the infant's food during the first year, is the continu- 
ous increase of weight, which, with the general blooming condition of the 
infant, represents a normal lactation. As in the case of all physiolog- 
ical rules, however, we must admit of certain variations which in espe- 
cial cases are as important for the infant's welfare as the rule itself, 
namely, the curtailing or lengthening of the period of lactation by a 
month or two, according to the season of the year, the eruption of the 
teeth, or the condition of the child, as in recovery from illness, it being- 
wiser to feed the infant from the breast during the heated portions 
of the year, and to wean in cool weather, either before or after the hot 
season, according to the individual circumstances of the case. 

An interdental period also is preferable to a dental period, on account 
of the possible disturbances which may arise in the latter, and interfere 
with the proper action of the new functions which are being called 
upon to perform their duties. Where there is an uncertainty as to the 
character of the milk which the infant is taking, especially in the latter 
months, though not so difficult to manage intelligently as the early 
period of the infant's life, it is much more likely to need careful super- 
vision than during the middle period, which, from its uninterrupted 
tranquillity, has been called the period of normal nutrition. Where 
the infant has, through an insufficient supply of milk in the mother, 
become for some time accustomed .to several meals of artificial food 
daily, the matter of weaning becomes a very simple one, for we know 
we have a food which will agree with it ; but where we have to begin 
to wean directly, and to adapt a food to the infant's digestive capabili- 
ties, as in cases of sudden failure of the milk or sickness in the mother, 
the procedure becomes much more intricate, and is at times fraught with 
considerable danger. 

Unless under very exceptional circumstances, sudden weaning is 
to be deprecated, though we must allow it is often done with impunity. 
The safest method, so long as we can never judge beforehand what 
infants will be likely to be unfavorably affected by sudden weaning, is 
to take plenty of time, and gradually ascertain, perhaps by frequent 
changes, which form of food is best adapted to the case. We then grad- 
ually limit the child to this food, omitting one by one the breast feeding, 
until finally we are sure that we have an artificial food on which the 
infant will thrive, with the proportion of starch, the new element which 
22 



338 Infant Feeding; Weaning. 

may now usually be introduced into the dietary, carefully adapted to 
its amylolytic function, which has but lately arrived at its full develop- 
ment, and which varies in different infants. When this change has 
been accomplished, the breast can with safety be entirely withdrawn. 

The danger of injudicious weaning must be guarded against. I 
will relate the following recorded case as an illustration of the impor- 
tance of careful consideration as to what effect some kinds of food 
have upon an infant : — 

Dr. Sinclair s Case (Boston). — "A rather delicate nursing infant, 
fourteen months old, and backward in its development, having cut only 
lour teeth, and being in the process of cutting four more, was, with- 
out the advice of the physician, suddenly deprived of the plentiful 
supply of breast milk of its healthy mother, in the latter part of Novem- 
ber, and fed upon oatmeal gruel. Vomiting and prostration immedi- 
ately began, and continued until the oatmeal was omitted and the 
breast resumed, when the infant began to thrive. Three months later, 
through ignorance of the cause of the first attack, the mother again 
weaned her infant suddenly, and again, without any preparation, fed 
it on oatmeal gruel. On the following two days the infant vomited 
incessantly, and was much prostrated. The oatmeal was then changed 
to barley, and this again to Mellin's Food. The symptoms, however, 
grew worse, and the thoroughly terrified mother again put the baby 
to her breast, with, however, this time a disastrous result, as her milk, 
from nervous influences, was so changed in its quality that it acted 
like a poison on the infant, which fell into a condition of collapse. 
Dr. Sinclair was sent for, and a few hours later had a healthy wet- 
nurse with a four-months baby procured, and after several days of 
complete prostration the baby began to revive, and somewhat later was 
gradually weaned without trouble. It may be well to add for the 
encouragement of those who may in their practise be so unfortunate as 
to have cases of this kind (as well as encouraging to the mother), 
that after the mother's milk had poisoned the infant — and when I first 
saw it the skin was gray and cold, the fontanels sunken, and the eyes 
fixed — yet recovery took place." 

The question of expense should not for a moment be considered 
by those who can afford to have an analysis made of the breast milk ; 
for not only will real benefit come to their own children through money 
spent in this way, but these analyses, by being published and collated, 
will prove of great value for the proper regulation of the feeding of 
infants in all classes of society. 

The mere microscopic examination of milk, beyond the determina- 
tion of the presence or absence of colostrum corpuscles, is too uncer- 
tain and misleading to be in any way depended on, the chemical analysis 
being the only practical method which can be recommended. 

There is, however, an error which we must always allow may inter- 
fere with the true analysis of the milk which the infant has actually 
received into its stomach at the end of the nursing, and which must 



Infant Feeding; Weaning. 



339 



necessarily invalidate the reasoning from our analysis. This has been 
suggested in what has been said in speaking of the changes which from 
slight causes may arise, and influence the especial specimen which is 
being analyzed. Thus, we should recognize that the milk varies con- 
siderably in its percentage of fat and total solids in the different 
periods of a milking, and that the composition of the milk which the 
infant has in its stomach may differ very widely from the composition 
of a specimen taken directly before or after nursing. 

Harrington's analysis of three portions of a milking will illustrate 
the meaning of what has just been said. 

TABLE III. 
(Harrington's Eighth Annual Report, Massachusetts State Board Health, 1884, p. 189.) 





Fat. 


Total Solids. 


Water. 


Ash. 


'^ Fore-milk'' 


3.88 
6.74 
8.12 


13.34 
15.40 
17.13 


86.66 
84.60 
82.87 


0.85 


''Middle-milk" 

''Strippings" 


0.81 
0.82 



We are already led to expect to find in the poor milks, those that 
do not agree with the infant, an excess of albuminoids and a diminu- 
tion of fat beyond what we have so far been able to determine as the 
normal average percentage of these two elements. Again, where a 
variation takes place in the milk, it is more likely to be found in the 
fat and albuminoids than in the sugar and total ash. We would also 
advise a number of analyses rather than one, in order that an error of 
an especial and temporary variation may be corrected. 

In the preceding pages great stress has been laid upon the impor- 
tance of feeding infants during the early months of life by means of 
human milk. We know that in civilized communities the necessity of 
supplying the infant with food not from the human breast will often 
arise, and artificial foods will in all probability be demanded, and that 
this state of affairs will increase rather than decrease as our civilization 
advances. With this prospect before us, and appreciating the diffi- 
culties which in a large number of cases are liable to arise when we 
attempt to adapt an artificial food to the wants of an infant, it mani- 
festly becomes a duty to endeavor to reduce the high mortality figures 
induced by artificial feeding. With this purpose in view, we should 
carefully investigate the different methods of feeding, and adopt some 
uniform plan for starting human beings in life ; for diversity and not 
uniformity is now the rule. With a very few exceptions, including the 
small percentage of inherited diseases which occur at birth, this 
diversity of method in feeding is the most prolific source of disease 
in early infancy. The group of symptoms which for want of a better 
name is represented by dyspepsia, — bad digestion, — occurs most fre- 
quently in the three periods when the infant's digestion is likely to be 
tampered with, namely, in the early weeks of life, when experiments 



340 Infant Feeding; Weaning. 

are being made to determine what will be the best to start with ; next, 
when, in addition to the irritation arising from the beginning of den- 
tition, new articles of diet are added to the original food ; and, thirdly, 
at the time of weaning, when there is often a sudden and entire change 
in the character of the food of the greatest comparative importance, 
because it is then when, as before stated, the stomach is in its most 
active period of growth, and when the function of digestion is estab- 
lished, and, following the rule of fundamental establishment, is in a 
state of unstable equilibrium. 

This demands the most careful regulation of the bulk of food 
given, to make it correspond to the rapid increase in the gastric 
capacity. We thus avoid the danger of overtaxing this capacity by too 
great volume in the beginning of nutrition, at the same time providing 
the sensitive developing function with the proper materials for nutri- 
tion, and thus avoiding by prophylaxis the dyspepsia of the later periods 
of infancy and childhood, the seeds of which are continually being 
sown in this early transitional period. We therefore have not only the 
question of infantile digestion, but also that of infantile development, to 
deal with. We should recognize the fact that the problem of artificial 
feeding is not a simple one ; and we can not too often reiterate that 
the question which but too commonly is supposed to be a simple one, 
and the one which in the greatest majority of cases is alone considered, 
namely, "Which food shall we give to the infant ?" is a misleading one 
and insufficient. It would seem, also, that the present is a most oppor- 
tune time for raising a note of warning against allowing our enthusiasm 
over any one especial theory to warp our better judgment. The feed- 
ing problem is a combination of factors of which the kind of food is 
only one ; and, personally, I have long been convinced that the neglect 
to investigate thoroughly and carry out in detail the combination of 
these by no means insignificant general factors has had much to do 
with our failure with artificial feeding in the past. If this fact is 
more uniformly insisted on in the future, it will prove to be of great 
value in the reduction of the mortality figures in the first two years of 
life. 

"To feed an infant one month old with six ounces of acid cow's 
milk every four hours, no matter if such a mixture has been sterilized, 
would be a radical offense against well-known anatomical and physiolog- 
ical laws." It therefore seems to me that time will be well spent in the 
discussion of the subject of artificial feeding, if we investigate and 
endeavor to copy, each in its turn, the various devices which nature 
makes use of; for we must admit that we are not in a position to 
improve on nature's method. It is certainly wiser and more economical 
not to spare expense and trouble in arranging the diet for infants ; for, 
as has been explained above, the period of active growth of an organ 
is the time when its functions are a prolific source of annoyance and 
expense in childhood and adolescence. Cheap foods and cheap methods 
of feeding, unless they are the best that can be procured, should not 



Infant Feeding; Weaning. 341 

be tolerated any more in the early feeding of infants than in adult life ; 
in fact, not nearly so much. We often, however, see a food recom- 
mended for a young infant because it is cheap and easily prepared, 
when it is well known that its lack of nutritions ingredients would, 
with adults, stamp it as unfit for food. 

In discussing the treatment of disease, we advocate what is best 
without reference to what it costs ; and then, in the especial case where 
the expense is an element which has to be taken into consideration, we 
endeavor to adapt our treatment to these considerations, but always 
approaching as nearly as possible to our first standard. In like man- 
ner we believe that we are doing wrong to the public if we allow our- 
selves to be handicapped in such a difficult question as infant feeding 
by the cry of expense. Infant feeding is an expense which is vital to 
the welfare of the human race ; and we can, without extravagance, safely 
relegate to the province of the manufacturers of patent foods the recom- 
mending to the public of foods which, if judged by the amount that is 
offered in bulk, are cheap, but which, when judged by their nutritious 
properties, are extremely expensive. 

Our scientific knowledge and clinical investigations have not yet' 
enabled us to follow nature exactly, and we therefore have not yet 
obtained an ideal method of artificial feeding. We must nevertheless 
go as far as the present state of our knowledge will allow, thus gain- 
ing a little ground every year ; and we must be especially careful not 
to be led astray by the fictitiously brilliant results which are reported 
from time to time in favor of certain foods. 

Instances are continually occurring where one food will fail, and 
another, when substituted for it, succeed; and yet these successes are 
merely temporary, and the mortality always remains far above that 
from human breast-milk. 

In nature's method of feeding, which must ever be remembered 
as the best and first, a receptacle, the human breast, which provides a 
fresh supply of food at proper intervals, absolutely prevents fermenta- 
tion of the food before it enters the infant's mouth, incites the action 
of the necessaiy digestive fluids, avoids a vacuum by collapsing as it 
gradually is emptied, thus allowing the food to flow continuously, and 
finally is practically self-regulating as to the amount of daily food 
according to the infant's age; secondly, the food itself is adapted to 
the infant's digestive function, and for its development, by its tempera- 
ture, 98 degrees to 100 degrees Fahrenheit, in its alkaline reaction, 
and its chemical constituents. Given these factors, how nearly can we 
approach them artificially ? Human ingenuity has not yet been able to 
devise anything which approaches the perfection of nature's receptacle, 
and the best we can do to offset this complex mechanism is to adopt 
that which is exactly the reverse, namely, a receptacle of absolute sim- 
plicity; and thus combat the tendency to fermentation by preventing, 
through perfect cleanliness, the receptacle from becoming a source 
of fermentation. 



342 Infant Feeding; Weaning. 

The rubber nipple takes the place of that of the breast, and a 
small hole near the end of the feeding tube prevents a vacuum being- 
formed and regulates the rapidity of the flow, while it allows it to be 
continuous; this is done by rolling up the edge of the rubber nipple 
from the hole with the finger, or letting it cover the hole, according to 
the demand shown by the infant. The artificial receptacle is not self- 
regulating, and hence we must determine anatomically the amount of 
food in bulk which nature provides for the average infant at different 
ages, and from these average figures deduce the proper amount for the 
special infant. The feeding-tubes are graduated for the most impor- 
tant periods of growth, for the purpose of continually impressing upon 
the mother and nurse what the physician often only has the opportunity 
of telling them at the beginning of the nourishing period, namely, that 
the error is in giving too much food rather than too little; an error 
which naturally results, when, as is commonly the case, the usual eight- 
ounce nursing-bottle is provided as the receptacle at the very beginning 
of infantile life. 

Ref rring again to Frolowski's investigation (see table 1, Gen- 
eral Rules for Feeding), we see that there is a very rapid increase in 
the gastric capacity in the first two months of life, while in the third, 
fourth, and fifth months the increase is slight. Guided by these data, 
which we find corresponding closely with the results of clinical investi- 
gations bearing on this point, we should rapidly increase the quantity 
of the food in the first six or eight weeks, and then give the same quan- 
tity up to the fifth or sixth month, unless the infant's appetite evidently 
demands more, when, of course, a gradual increase should be made. 
A considerable increase in the quantity needed takes place, also, 
between the sixth and tenth months. 

Of the different causes which regulate the gastric capacity, the 
weight of the infant has the greatest influence, and it is perfectly pos- 
sible for a poorly-developed infant of small weight to have a gastric 
capacity no greater than a normally developed infant of half the age. 
This possibility must be taken into account when we attempt to regu- 
late the bulk of an artificial food to the age of the infant. We have 
seen an infant six weeks of age whose general development and weight 
corresponded so closely to those of the general average infant of twelve 
weeks, that it was self-evident that the two ounces of food which would 
ordinarily have been the proper allowance, so far as its age was con- 
cerned, was not sufficient, and that its weight indicated a gastric capacity 
for an allowance of four ounces ; and in fact it took this amount, and 
digested it with the greatest ease, while with any less than the four 
ounces it was never satisfied. 

Another very important influence on the gastric capacity is the 
kind of nourishment which the infant has received. 1 The breast-fed 
infant in the early months of life has a uniformly developed stomach, 
and, as a rule, of smaller capacity than the stomach of the artificially 

1 Fleischmann, "Die Erniihrung des Sauglingsalters, 1 ' p. 17. 



Infant Feeding; Weaning. 



343 



fed, the muscular fibers of the fundus in the latter stomach being weak 
and its form abnormal. 

It is common in the artificially fed, where the quality of the food 
is poor and the quantity too large for the age and development, and 
where rachitis has been a consequence, to find the t stomach dilated to 
a capacity entirely out of proportion to the infant's age and weight. 

The figures in table 1 provide us with a fair working basis by 
which we can determine the amount of food to be given at different 
ages, so as to correspond to the marked periods of the stomach's growth. 

Figures 27, 28, 29, and 30 represent feeding-tiibes drawn on a scale 




<cS 









oo 




Fig. 



Fig. 28. 



Fig. 29. 



Fig. 30. 



of about one-third, and have the proper capacity for the amount of 
food which should be given to the infant during these periods. 

Figure 27 is a tube of small caliber, graduated to hold two ounces, 
and intended to be used for feeding during the first six weeks of life, 
and later as a measure for the larger tubes in preparing the artificial 
food in its varying proportions. 

The tube 28 holds four ounces, and has a caliber of one and five- 
eighths inches and a height of six inches; it is to be used from the 
sixth week to the fifth or sixth month, and is intended to correspond 
to the above-described rapid growth of the stomach in the first two 



344 Infant Feeding; Weaning. 

months, and its significant further increase in size up to the fifth and 
sixth month. It is represented in the diagram with the nipple adjusted 
for use. 

The large tube, Figure 30, has a caliber of one and six-eighths 
inches, and a height of eight and three-fourths inches, corresponding to 
the common half-pint nursing bottle. It is represented in the figure 
without the nipple, and shows the air-hole, which, together with the 
mouth of the tube, is stopped with cotton. Another medium-sized tube 
has been made to go with the set, and this has a caliber of one and six- 
eighths inches, a height of seven and three-fourths inches, and holds six 
ounces. It is not a necessity, but is intended to be used between the 
sixth and tenth months, merely to enunciate the importance of careful 
supervision of quantity throughout the first year, as where a food qual- 
itatively correct is being used, the error, as a rule, is in giving too 
great amount. It is represented in Figure 29. 

A few words regarding the process of sterilization and the con- 
nection of bacteriology with the feeding problem will here be neces- 
sary, as explanatory of what will be said later about especial artificial 
foods. The practical utility of destroying the developed bacteria in the 
milk in certain intestinal disorders has long been recognized clinically. 
Jacobi many years ago recommended that the milk to be used for the 
infant during the day should be boiled as soon as received, and kept in 
tightly-stoppered bottles, inverted on ice. Lister has shown that cow's 
milk as it comes from the udder is sterile, and that it quickly becomes 
infected in various ways, as by the hands of the milkers, the air of 
the stable, etc. 

Professor Soxhlet, of Munich, found that calves one week old, 
when taken from the udder and fed with their mother's milk from a 
trough, were affected with diarrhea, which disappeared on their being 
fed again directly from the udder. Soxhlet's experiments also showed 
that under the same condition of temperature the milk of three cows 
as ordinarily milked, turned sour in about half of the time that the 
same milk did when the udders and milker's hands were carefully 
washed, and other precautions for cleanliness were taken before milk- 

Dr. Ernest's advice several years ago was to sterilize the milk in 
a receptacle from which the infant can be fed without pouring from 
one vessel to another, and thus running the risk of fresh infection, and 
this method is now in general use in cities. A single steaming, how- 
ever, may not destroy the spores which may be developed later, unless 
the process is several times repeated. A single steaming, or the first 
sterilization, or killing of the germs, is in all probability all that is 
necessary for immediate use for the purpose of feeding. 

Figure 31 represents the sterilizers with the water boiling under 
the liter flask, which is stopped with cotton, and the four-ounce feed- 
ing-tube, with its mouth, its nipple, and its air-hole tightly inclosed 
in rubber cot, as described on the following page. 



Infant Feeding; Weaning. 



345 



A gas flame is preferable to that of an alcohol lamp. This 
steamer answers very well for sterilization, such as is necessary in 
infant feeding. It is simply a tin pail eight or nine inches in diam- 
eter, and nineteen or twenty inches deep, raised on three legs suf- 
ficiently high to allow a burner to stand under it. (Bunsen's burner 
is a good one.) Four inches from the bottom of the cylinder is a 
perforated tin diaphragm on which the feeding-tube stands while being 
sterilized. There is a small vent for the escape of the steam in the 
cover. Water is placed in the bottom 
of the steamer to the depth of about 
an inch, and in about ten minutes after 
lighting the gas-jet, the water begins 
to boil. The food is then poured into 
one of the feeding-tubes, and an or- 
dinary rubber nipple adjusted as on 
any nursing-bottle. Over the nipple, 
as an extra precaution for the exclu- 
sion of contamination, a non-perforated 
rubber cot is drawn tightly down on 
the tube. As soon as the water has 
been boiling for a minute or two, the 
tube is placed in the steamer, the cover 
applied, and the steaming continued 
for twenty minutes. The tube can 
now be removed, allowed to cool until 
of a proper temperature, 98 degrees to 
100 degrees Fahrenheit, and on remov- 
ing the rubber cot and putting the 
nipple in the infant's mouth, the food 
is received as sterile as from the human 
breast, so far as the developer bacteria 
are concerned. Food sterilized in. this 
way can be kept for a number of days, 
and can be utilized when the infant- 
is to be taken on a journey. Where 
long journeys are to be taken, such as 

an ocean voyage, or across the continent, the sterilization should 
be repeated several times with intervals of a day, and the flasks 
used for the sterilization hermetically sealed. Food prepared in 
this way will keep sweet for weeks. Where the steamer just described 
can not for any reason be obtained, and also the gas or an alcohol lamp, 
as off in the country, for instance, a simple colander or potato steamer 
with a close-fitting lid, with a small outlet for the steam to escape a 
little, may be placed on the teakettle, and makes an effective sterilizer. 
The food can also be sterilized by immersion in boiling water, or by 
directly boiling the food itself. 




Fig. 31. 



346 Infant Feeding; Weaning. 

The question as to whether the milk should be boiled or steamed 
is not one of a great deal of significance, and can be settled according 
to the fancy of the individual practitioner, the object of sterilization 
being accomplished in either case. 

"Boiled milk does not become sour as quickly as raw milk, due, 
of course, largely to the fact of its sterilization." 

As to the effect boiling has on the digestibility of milk, there is 
difference of opinion. There is a general impression that boiled milk 
is . more constipating than new milk, which is probably derived from 
the fact that milk sterilized by boiling is less likely than raw milk to 
cause diarrhea. 

According to Schreiner 1 and to Randolph, 2 boiled milk is more 
quickly coagulated by acids than raw milk, while the reverse is the 
case with regard to the action of rennet. Thus, raw milk at the body 
temperature coagulates firmly almost immediately on the addition of 
a neutral rennet solution, whereas, boiled milk under the same condi- 
tions does not clot for a far longer period, and the coagula are not so 
firm. The odor and taste of boiled milk are present when milk is 
steamed, but to a much less degree than with boiled milk; and while 
a thick scum is formed on milk boiled for twenty minutes, which is 
tenacious and does not disappear on shaking, only a very thin scum 
forms on milk steamed for twenty minutes, and this is not tenacious, 
and almost entirely disappears on shaking. The writer prefers the 
steamed milk to the boiled. It is also more palatable. 

Taking the average breast milk as the safest standard, we are 
impressed with the fact that the helpless young animals and the young 
of human beings are carnivorous ; also that although a vegetable diet 
would oftener seem far the easiest method of procuring nourishment 
for our young infants, yet nature has persisted in providing an animal 
diet. We should therefore be very cautious about endeavoring to intro- 
duce into our artificial diet a vegetable element, which, as judged by 
our standard, must be a foreign element. 

Milk is the food which our reason tells us should be given to the 
young infant, and a milk which will approach as nearly as possible 
to the average human milk. That of various animals has from time 
to time been recommended as the best substitute for human milk, the 
recommendation being based on their analysis approaching more or 
less nearly the composition of human milk. The milk, however, of 
all animals has to be modified to correspond to human milk ; and when 
we begin to modify, it is easy to change the proportions of the different 
constituents to a great degree as well as to a small degree. The fact 
that one animal's milk approaches in its analysis more nearly to human 
milk than another is not of much significance, other considerations being 
far more important ; and it is most important of all that we should 
use one which can be obtained everywhere, all over the world, by the 

1 Loc. cit. 

Philadelphia Medical Neios, June 21, 1884. 



Infant Feeding; Weaning. 347 

people at large. This at once settles the question that it is the milk of 
the cow to which we must turn our attention. Cow's milk may differ 
in its composition from human milk to a greater degree than does the 
milk of the ass or the mare, whose milk approaches, so far as is shown 
by analysis, most nearly of all animals to that of woman; but this in 
all probability is for the reason that cow's milk is so universally used 
as a food for human beings of all ages. 

If the ass and the mare should become domesticated as a food 
supply to the same extent that cows have been, there is every reason 
to suppose that their milk might change in its composition, and their 
comparatively undeveloped mammary glands increase in size, just as 
has been the case with the cow, an animal which for thousands of years 
has been used for the production of milk, as is now the case. In fact, 
in Egypt, 1 where formerly there either was no trade in milk or very 
little, we find the cow represented on the monuments with only slightly 
developed adder, a fact of some significance when we remember the well- 
known tendency of the Egyptians to realistic representations. It is 
then from public demand, and by breeding, that cows have been made 
to produce so much more milk than is necessary for the support of their 
young. Xot only quantitative but qualitative differences exist in 
animals according to the development of their mammary glands ; and 
as Martini 2 has shown, the development of their mammary glands 
determines the quantity and quality of the milk which produces it. 
The question of artificial feeding, then, is practically reduced to some 
modification of cow's milk; for this is the milk which is most easily 
procured everywhere, and as the milk of all animals must be modified 
for the human infant, it is as easy to deal with cow's milk as with 
any other. 

A further exemplification that cow's milk is practically the uni- 
versal source of the artificial food supply for infants in most civil- 
ized communities, is the fact that various foods, patent or not, all 
depend for their basis on cow's milk, and that without this addition of 
milk they would show but an insignificant percentage of many of the 
most important ingredients of the food. So, logically, we should not 
speak of the various foods as such, but merely as adjuvants to cow's milk ; 
and if this is thoroughly understood, it will, in many minds, do away 
with much apprehension regarding the apparently successful results of 
innumerable foods which in reality, when given to the infant, are 
merely a means of modifying the almost universal representative of 
the artificial foods — cow's milk. 

Cow's milk, therefore, should be carefully compared with the 
standard of human milk, in order that we may know how nearly it 
resembles it. Table 1 is a comparison of the average human milk 
and the average cow's milk, the figures representing the later and more 
reliable analysis. 

^Stumpf, Deutsche* Archiv. /><;• Klinisch Med., January 18, 1882. 

2 B. Martiny, "Die Milch, ihr Wesen und ihre VerwerthinoV' Danzig 1872. 



348 



Infant Feeding; Weaning. 



TABLE IV. 



# 


Woman's Milk Di- 
rectly FROM THE 
Breast 


Cow's Milk as Ordinarily 
Keceived, about Twenty- 
four Hours Old 


Reaction 


Slightly Alkaline 


Slightly Acid 


Coagulabte A Ibuminoids 


Small Proportionately 


Large Proportionately 


Coagulation by Acids 


Not perceptible 

in 

test-tube 


Marked in test-tube ; greatest in 
pure milk ; less with milk 
diluted with water, and 
when 1 to 5 is not perceptible 



Water 


87-88 


86-87 


Total Solids 


12-13 


13-14 


Fats 


4 


4 


Albuminoids 


1 


4 


Milk-sugar 


7 


4.5 


Ash 


0.2 


0.7 


Bacteria 


Not present 


Present 



We must recognize, however, that infants in general, as repre- 
sented by those who live in cities and large towns, do not receive their 
supply of milk at once from the cow's udder, but that the milk, as a 
rule, is about twenty-four hours old; and it is therefore cow's milk 
twenty-four hours old that, until further improvement is made in deliv- 
ering milk, we must compare with fresh human milk, and modify to 
correspond to it. 

Before speaking of the various modifications of cow's milk which 
are necessary to make it correspond to human milk, it will be well to 
say a few words about its properties, as represented in table 4. 

The reaction is stated to be slightly acid; and this is the case 
whether it has stood twenty-four hours with ordinary care or whether 
it is tested directly from the udder. This has been determined by direct 
experiment, so that practically the same amount of modification will 
be correct for the first twenty-four or thirty-six hours, so far as the reac- 
tion is concerned. 

Of the total nitrogenous constituents of the milk, which are 
classed under the general term of albuminoids, and of which the casein 
and the albumen are parts, the coagulable albuminoids are proportion- 
ately larger in amount in cow's milk than in human milk, so that under 
the same conditions a larger curd will be formed with the former than 
with the latter. 

Table 5 gives the results of these experiments, which may prove 
to be of considerable value. (Dr. Harrington and Dr. Townsend.) 

table v. 



Equal volume of fluid in test-tubes. Ten drops of acetic acid 
added to each test-tube. Each test-tube inverted slowly three times, 
so as to insure thorough, equal, and uniform mixing in all. 



Infant Feeding; Weaning. 349 

1. Woman's m.ilk ISTo perceptible curd to the eye 

2. Cow's milk, raw Large curds 

3. Cow's milk, boiled Same as JSTo. 2 

4. Cow's milk, sterilized by steam Same as Eo. 2 

5. Cow's milk 2 parts \ ^. , 

Water 1 part. J Fmer tllaa 2 " 

6. Cow's milk 2 parts ) 

Lime-water . ..1 part, j Same as 5 ' 

The albuminoids, as shown in the table, are four times as great 
in amount in cow's milk as in woman's, while the milk-sugar holds the 
relation of 7 in woman's milk to 4.5 in cow's milk; the ash, on the 
contrary, is in woman's milk only 0.2, while in the cow's milk it is 0.7. 

In cow's milk, as commonly used for food, we must recognize the 
presence of bacteria. 

The question is now reduced to the different methods employed in 
modifying cow's milk. This may be done by diluting with water, by 
concentrating it and diluting it when used, or it may be modified by the 
various patent foods or by any other adjuvant, such as barley water, 
lime-water, or cream. 

The following table has been prepared to show the analysis of the 
different modifications as they are given to the infant, and to serve as a 
reference table to the physician or nurse, who by this means can readily 
see how near to or far from the standard of human milk they are get- 
ting when they decide to use one of these modifications. 



TABLE VI. 

COMPARISON OF WOMAN^ MILK WITH COW's MILK AND COw's MILK 

MODIFIED. 

(The figures are approximate and represent general averages.) 



Material 



Woman's milk 

Cow's milk 

Cow's milk, 2 parts 

Water, 1 part 

Cow's milk, 1 part.. 

Water, 1 part 

Cow's milk, 1 part 

Water, 2 parts.. 

Cow's milk, 1 part 

Water, 4 parts , 

Condensed milk, 1 part. 



Reaction 


Starch 


Water 


Total 
Solids 


Fat 


Albumin- 
oids 


Sugar 


f slightly "1 
\ alkaline J 





88 


12 


5. 

4 


i 


7 


slightly acid 





86.8 


13.2 


4 


4 


4.5 


("slightly I 
\ acid J 





91.20 


8.80 


2.6 


2.67 


3 


J slightly ) 
] acid / 





93.40 


6.60 


2 


2 


2.25 


("slightly ~l 
\ acid / 





95.60 


4.40 


1.3 


1.33 


1.50 


(slightly ~) 
\ acid J 





97.36 


2.64 


0.8 


0.8 


0.9 


neutral 





28 


72 


10 


10 


50 



0.7 
0.4 

0.3 

0.23 

0.14 
2.0 



350 



Infant Feeding; Weaning. 



Material 


Reaction 


Starch 


Water 


Total 
Solids 


Fat 


Albumin 
oids 


Sugar 


Ash 


Condensed milk, 1 part.. 
Water, 9 parts 

Condensed milk, 1 part.. 
Water, 15 parts 


< neutral i 

< neutral I 

acid 

-j acid v 










90.31 

93.92 
62.87 

94.02 


9.69 1.3 

6.08 0.88 
37.13 10.8 

5.98 1.75 


1.35 6.75 

0.83 4.3£ 
10.27 13.78 

1.65 2.22 


1 0.26 
► 0.17 


Loefland's sterilz'd milk 

Loefland's sterilized 
milk, 1 part 


2.23 
0.36 


Water, 6 parts 






Nestle 1 s Food — 

Albuminoids 8.23 

Pat 1-91 


1 

1 

\- neutral 

1 


3.65 


91.75 


8.25 


0.17 


0.75 


3.54 




Sugar 38.92 

Ash 1.59 




Starch 41.10 


0.14 




1. 
Water 10. 




11 




Imperial Granum — 
fat 101 


1 
1 

! slightly 
acid 


2.36 


92.88 


7.12 


0.03 
1.33 


0.31 
1.33 


trace 
1.5 




Albuminoids 10.51 

Sugar trace 

Ash 1.16 

Starch 78.93 


0.03 
23 






3. 

Milk 32.1 

Water 64. 


1.36 


1.64 


1.5 


0.26 


99. 




Mellin's Food — 

Fat 0.15 

Albuminoids 5.95 

Sugar 48.20 


slightly 
acid 

J 


present 


91.74 


8.26 


0.004 
2.0 


0.17 
2.00 


1.44 
2.25 




Ash 1.89 

Starch present 


0.05 
0.35 


3. 

Milk 48. 

Water 48. 

99. 


2.004 


2.17 


3.69 


0.45 


Barley Water, as usually 
made with Kobinson's 
Barley, contains — 

Starch 1.4 

Milk .2. 


1 

J- acid 

1 


0.47 


90.75 


9.25 


2.66 


2.66 


3.0 


.046 


3.4 




BiederV s Cream Mixture 
for Infants, 3 mos. — 

Cream oz. 1 

Milk oz. 1 

Water oz. 3 

Milk-sugar dr. 1 


-acid 





91.56 


8.44 


2.7 


1.8 


3.8 


.014 



Infant Feeding; Weaning. 



351 



Material 


Reaction 


Starch 


Water 


Total 
Solids 


Fat 


Albumin - 
oids 


Mjar 


Ash 


Meig's Mixture — 
Cream, 14 to 

16 fo fat oz. 2 

Milk oz. 1 

Lime-water oz. 2 

Sugar-water oz. 3 

Milk-sugar dr. 17| 


! 

strongly 
| alkaline 

i 
J 





88.35 


11.62 


3.50 


1.21 


6.66 


0.25 


8 
Water, one pint. 




Mixture recommended — 
Cream (centrifugal), 

I to £ % fat, 

diluted oz. 2 

Milk oz. 1 

Lime-water, 

diluted f oz. 2 


1 

slightly 
[ alkaline 





88.42 


11.58 


4 


1.11 


6.26 


0.21 






oz. 8 
Water oz. 3 





Note. — To prepare one pint of food for use in twenty-four hours: Take milk and 
cream (20%), as soon as it comes in the morning, and mix as follows: Milk, 2 oz.; cream, 
3 oz.; water, 10 oz.; milk-sugar, 2 measures (one measure is 3^ drams). Place in a 
flask in steamer for twenty minutes; then remove the flask from the steamer, and when 
still slightly warm, add lime-water, oz. j, and place on ice, and give the proper amount 
at the proper feeding times. (See table 1.) 

In considering the preparation of various foods with reference to 
making them correspond in their analysis as nearly as possible to human 
milk, the question is somewhat simplified if we recognize the fact that 
although the percentage of the ingredients of human milk vary under 
certain circumstances, yet, as has already been explained in an earlier 
part of this chapter, so far as the age is concerned, in the early months 
there is so little difference that a variation is as likely to occur between 
different milks of the same age as in the same milk at different ages, 
so that we are probably doing wisely not to change the percentage of 
the ingredients, but as the infant grows older, give a food qualitatively 
uniform, but of varying quantity. 

There is a very large number of patent foods, but they all claim 
about the same advantage, and closely resemble one another in their 
constituents and in their endeavor to make cow's milk easily digestible, 
and also to make their resulting analysis agree as closely as possible 
with human milk. 

Rotch, M. D., has given the following method of preparing food 
for household use. It is one of the best :— 

"We will suppose, by way of illustration, that we are using a 
centrifugal cream of twenty per cent of fat. (See table.) We dilute 
this cream one-quarter, and make this diluted cream, containing fifteen 
per cent of fat, one-quarter part of the whole mixture. It was found 
by Meigs that the proper percentage of sugar in the mixture was 
obtained from a solution of milk-sugar seventeen and three-fourths 



352 Infant Feeding; Weaning. 

drams to one pint of water. In the analysis of the mixture I have 
found that the sugar percentage was, if anything, usually somewhat 
under seven per cent ; so that to simplify the figures, and without run- 
ning any risk of appreciably changing the percentage from seven, I 
have added eighteen drams of milk to the pint of water. In the 
same proportion we find that in every three ounces of water there 
should be three and three-eighths drams of milk-sugar, and that this 
three and three-eighths drams should be the amount for every half- 
pint of the mixture. I then had a tin measure made to hold three and 
three-eighths drams of milk-sugar, which obviates the expense of hav- 
ing the milk-sugar put up in packages by the apothecary, and is suf- 
ficiently exact not to alter the sugar percentage in the mixture. One 
of the leading apothecaries sells a pound of the highest grade of milk- 
sugar for fifty cents, and gives with it one of these measures. Any 
measure which holds three and three-eighths drams will answer. 
The milk-sugar can be obtained from first-class drug stores. Hence 
all mothers and nurses can follow the directions in preparing the 
infant's food." 

It is well to remember, also, that the pound of sugar contains 
seven thousand grains, and that if we wish to have it divided into 
packages of three and three-eighths drams, and to pay about one dollar 
and a quarter instead of using a measure and paying fifteen cents, we 
can order thirty-five packages to be made from the pound, and we shall 
still have the resulting percentage in the mixture substantially correct. 
We must also remember that the proportion of lime-water should be 
one-sixteenth part of the whole mixture, that is, one-half ounce for the 
half pint. 

Rotch found on steaming a mixture of cream, milk-sugar, water, 
and lime-water in the usual way for twenty minutes, that the liquid 
had become a light brown color. Dr. Harrington found that the color 
was due to certain brown products formed by the action of the lime- 
water on the milk-sugar at a high temperature. This color itself does 
not alter the value of the mixture ; but Dr. Harrington also found that, 
while at the beginning of the steaming the reaction of the mixture was 
strongly alkaline, this reaction grew gradually less as the steaming was 
continued, and at the end of the steaming, the mixture might be neutral. 
This change in the reaction Dr. Harrington supposed to be due partly 
to the formation of a compound of lime and sugar, and partly to the 
fact that on heating lime-water, much of the lime is thrown down, so 
that, as the object of the lime-water is to render the acid mixture alka- 
line, this object is defeated when the mixture is sterilized. The lime- 
water, therefore, should not be added until after the mixture has been 
steamed and partly cooled. 

To prepare food to be used for twenty-four hours, see Figure 9 for 
ents are given to make up a half pint of the mixture, it is a sufficient 
method of sterilization. When the proportions of the various ingredi- 
rule for preparing larger quantities, such as a pint or a quart. The 



Infant Feeding; Weaning. 353 

directions to be given for preparing a half pint of the mixture by this 
method are very simple, and can be carried out by individuals pos- 
sessed of a very small amount of intelligence. 
Mix as soon as received in the morning: — 

Cream 1 (20 per cent fat) . . . 1% ounces 

Milk 1 ounce 

Water 5 ounces 

Milk-sugar, one measure, or 3% drams 

Steam the mixture in the bottle for twenty minutes, after having 
introduced it by means of a funnel, in order to keep the neck of the 
bottle dry. The bottle is to be stopped tightly with a cotton plug. 
After steaming, remove the bottle immediately and allow it to cool par- 
tially; then add half an ounce of lime-water, and keep on ice. If in 
the country where there is no ice, it should be prepared twice in twenty- 
four hours, and kept in cold water. This is the simplest way of pre- 
paring the food, and will probably prove to be the most practicable as 
well as the most popular ; but, of course, it is open to the objection that 
every time the infant is fed, the cotton has to be removed from the bot- 
tle, with resulting danger of contamination of the remaining fluid, 
which is but slight if the tube is quickly restoppered. Where, however, 
as in very hot weather, this objection is found to be a valid one, small 
bottles for each feeding should be used. 

A good plan is to have eight or ten flasks, all stoppered with cotton 
and having their mouths carefully dried, as was directed for the large 
liter bottle. In this way the food for twenty-four hours can be pre- 
pared by one steaming ; and as the cotton is not removed until feeding- 
time, the mixture will keep indefinitely, and need not be put on ice. 
When this method of preparation is used, the proper amount of lime- 
water is to be added to each feeding. 

There has been much complaining about the preparation of food 
with cream and milk-sugar ; and it will be interesting to examine into 
the actual expense incurred in using this mixture. 

The cost of feeding an infant three or four months old will repre- 
sent approximately the cost for the most important part of the feeding 
period, and the one which is the most difficult to manage. This cost 
amounts to about twelve cents a day, and there are very few parents 
who are unable to pay this for their infant during the early months of 
life. The expense of feeding in this way can not be said to be beyond 
the means of the people at large; so that, although the food and its 
methods of preparation are the result of scientific investigation as to 
what is best without regard to cost, the actual daily expense happens to 
compare well with what we can reasonably demand as the price which 
the poor should be expected to pay for the nourishment of their off- 
spring. 

'Ordinary cream from the common herd, which is about as thin as the dealer's 
machine will make it, is really of very good quality, and we can count on its containing 
about twenty per cent of fat. 

23 



354 Infant Feeding; Weaning. 

In conclusion, we can fairly say that it is possible in artificial 
feeding to approach the standard human breast milk much more nearly 
than is usually attempted, and there is no reason why clinical results 
should not be greatly improved, if physicians will only take additional 
time and trouble to follow more uniformly nature's teachings. In all 
classes of life, a much greater amount of time, expense, and thought 
is given, proportionately, to the preparation of food for the adult of 
the family than for the infant. This is a mistake, both from a humani- 
tarian and from an economical point of view; for the infant is much 
more susceptible to irregularities of diet, with their resulting suffering, 
thian is the adult ; and when once the train of symptoms usually called 
dyspeptic is established, infinitely more trouble and expense are entailed 
than if more exact methods of feeding had been adopted before the 
digestion was disturbed. In the early weeks of lactation, after the mam- 
mary function has been fully established, where it can be afforded it is 
well to have a number of analyses made of the mother's milk, and to 
keep the results as a control-record to act as a guide for the preparation 
of an artificial food in case, as so frequently happens, something should 
occur to end the nursing at an early period. It is highly probable 
that the digestive functions of the individual infant may have certain 
idiosyncrasies which correspond to some idiosyncrasy in the percent- 
ages of its mother's milk; and in case of difficult digestion, where the 
artificial food, which has been made to correspond with the analysis 
of average woman's milk, fails to agree, reference to this control rec- 
ord may give the solution of the problem sooner than if we have to 
ascertain experimentally, by changing in turn the percentages of the 
different ingredients, in which particular ingredient the idiosyncrasy 
of this especial infant is to be found. The assistance of the skilled 
chemist is too little sought after in determining these questions of infan- 
tile digestion and nutrition, and in the future must necessarily be made 
use of if there is to be any advance for the better in the subject of 
artificial feeding. 

Where an infant, then, is to be fed with artificial food, give pre- 
cise directions as to the time of feeding, the amount at each feeding, 
and the feeding apparatus which is to be used. See that the analysis 
of the food corresponds as closely as possible to that of human milk. 
Give instructions as to the proper temperature of the food. See that 
the reaction is slightly alkaline, and then if there is any difficulty with 
the digestion, sterilize the food. If this is not successful, refer to the 
control-record of the mother-milk, if you have one, and adapt the food 
to any material idiosyncrasy shown by this record. If no control rec- 
ord has been kept, experimentally try to discover the especial idiosyn- 
crasy of the individual infant by changing the percentage of the fat, 
sugar, albuminoids, or ash. 

The writer has found Harlock's malted milk prepared according 
to the directions on the label, to be very useful in starting infants in 
early life. It does not curdle in the stomach like raw milk. 



CHAPTEE XX. 
WET-XUKSES. 

A physician, and no other one, should assume the responsibility 
of selecting a wet-nurse. Some experienced practitioners disapprove 
entirely of the employment of a wet-nurse, because the risks are so seri- 
ous, and it is so difficult to avoid them fully. The milk must be nutri- 
tious, and adapted to the infant; but the risk of the infant's contract- 
ing some serious disease must be avoided. 

The moral character of the woman must be considered. While 
most probably her milk can not influence the future moral organization 
of the growing child, yet her close association with the infant may 
make a permanent impress on its pliant brain. Moreover, the woman 
will bear a close and peculiar relation to the family into which she is 
introduced, and if she has a bad temper, could cause no little unhap- 
piness. She soon learns, or believes, that her services can not be dis- 
pensed with, and she may become an unbearable tyrant. If of intem- 
perate habit, she, when in a state of intoxication, may injure the 
infant either by accident or design, and at that time will furnish milk 
of an injurious character. Authenticated cases have been reported of 
convulsions even occurring in infants because of milk altered by a vio- 
lent temper and mental disturbance. Moreover, a woman of bad tem- 
per, or one without due sense of responsibility, may leave suddenly, 
possibly when the child can not bear the consequent abrupt change in 
diet. The wet-nurse should be cheerful, active, good-natured, temper- 
ate, moral, and of average mental capacity. By preference she should 
be married ; but in this country married women do not often undertake 
wet-nursing. If her child is illegitimate, it is best that it should be 
her first child. There is some danger of a wet-nurse exposing her- 
self to the contagion of such diseases as measles, scarlatina, etc., and 
conveying the poison to the child. 

Generally, in America, the woman is entirely separated from her 
own offspring, and the latter, if living, is placed either in some home 
for infants, or is given into the care of some woman to be fed arti- 
ficially, and usually to die. A proper appreciation of the moral obli- 
gation involved should induce the parents of the favored child to make 
due efforts to secure the proper care of the infant deprived of its natural 
rights. It is also in the interest of their child to exercise this humane 
act, for a knowledge on the part of the wet-nurse that her child is 
receiving kind attention, will go far toward securing that mental equa- 
nimity which is necessary to the furnishing of a proper amount of suit- 
able milk. 

(355) 



356 Wet-Nurses. 

A good wet-nurse should be robust and strong, but not very fat. 

A scrofulous woman can not furnish good milk. Existing tuber- 
culosis, or the tuberculous taint as indicated in the family history, 
should exclude her as a wet-nurse. 

A woman who has suffered with rachitis in her childhood should 
be rejected. 

The most important constitutional disease to exclude is syphilis. 
She must be cross-questioned as to the multiform manifestations of the 
disease. Inspect the skin, mouth, throat, nasal passages, and see if 
there is any characteristic cicatrices. 

A syphilitic woman can not give milk duly nutritious ; and there 
is almost a certainty that the child will become infected through some 
syphilitic lesion; it may be of the nipple or the breast, or of some 
other part of the person, as of the lips, the tongue, etc. 

Neither should a syphilitic child be allowed to be wet-nursed, for 
the infant will probably infect the wet-nurse. In Prussia the latter is 
punishable by a special law. 

The infant should be examined to determine the presence of 
syphilis. 

The hypochondriacal woman should also be rejected. She can not 
furnish the best milk, and the hypochondria may eventuate in insanity 
under the strain of lactation and of separation from her own child, 
or in the case of its death. 

All acute diseases, unless trivial in character, whether contagious 
or not, render the woman unsuitable. 

Pregnancy, of whatever duration, renders the woman unfit, because 
very frequently the consequent alteration in the character and diminu- 
tion in the quantity of the milk renders it decidedly insufficient and 
deleterious. 

If she menstruates, the milk is usually so altered at the period as 
to disagree; and a menstruating woman should not be engaged unless 
it is known that her milk remains good during the period, or the demand 
for a wet-nurse is exceedingly urgent. It is repeatedly seen that a 
nursing child is made ill by the milk of its mother taken during the 
menstrual flow. 

Nature has not intended that lactation and pregnancy or lactation 
and menstruation should co-exist. 

There may be abnormal conditions of the genitals. The appli- 
cant for the position of wet-nurse may deny the existence of any symp- 
toms of genital disease, yet a skilful questioner may secure the needed 
information. It will be safer, however, to insist upon an examination. 
Chancroids and vegetations are positive contra-indications. Gonor- 
rhoea! tubal disease is a decided contra-indication, even though evidence 
of existing vaginal or urethral gonorrhoea can not be ascertained. 

Ovarian cyst-bibeo-myomata, or sarcoma, or carcinoma should lead 
to the woman's rejection. 

A protracted lochial flow indicates usually subinvolution, with or 



Wet-Nurses. 357 

without some other lesion, such as laceration, ulceration, or polyp. 
Such conditions render the woman unfit in proportion to their effect 
upon the general health. 

The woman who refuses to submit to an examination must be 
declined. The breasts must be examined to determine their capacity 
for the formation of milk, and their fitness for giving milk. 

The well-shaped breast of the primipara is conical, and does not 
drag. If a multipara, the breast hangs somewhat downward as a 
result of previous nursings. A large breast may be merely a mass of 
adipose tissue of the mammary gland in it. The breast that consists 
chiefly of adipose tissue diminishes but little in size as the infant nurses, 
whereas the mammary gland furnishing a good supply of milk becomes 
decidedly smaller and less tense after the child has emptied it. The 
latter breast also enlarges and becomes more tense at the expiration of 
two or three hours. The breasts must be examined for fibroma, carci- 
nomata, and tuberculosis. The contagiousness of carcinomata and of 
tuberculosis of the breasts through the milk is at least so probable that 
no risks should be taken. Lancereux describes a diffused and a circum- 
scribed syphilitic mastitis. The diffused form is usually bilateral, and 
consists of an indolent induration without discoloration of the skin, 
almost painless, but attended with enlargement of the axillary glands. 

The nipple may present syphilitic fissures or ulcerations. Even 
if the mother should have escaped infection prior to and during preg- 
nancy, she may contract a primary sore on the nipple or breast from a 
syphilitic lesion of her child, such as a mucous patch of the mouth or 
a fissure of the lip. Any syphilitic lesion of the breast, whether pri- 
mary or secondary, the latter especially if moist, is liable to infect the 
child wet-nursed. 

Tuberculosis of the breast not infrequently escapes observation. 
The most usual forms are the cold abscess and the chronic fistula. A 
disseminated form exists in which the nodules are of various sizes and 
are hard to the examining fingers. They are liable to caseous degenera- 
tion and softening, or to calcification. In this variety the breasts are 
but slightly enlarged from the deposits, and may be movable over the 
ribs. There is a confluent form of mammary tuberculosis in which the 
swelling is more marked. Nodules can be felt as irregular, somewhat 
lobulated, and, it may be, immovable masses. Fistula? are liable to 
occur. A true miliary form may exist as an early manifestation of 
mastitis, and cicatrices or indurations, with a history of previous inflam- 
mation, render the woman unfit. The nipple should be neither too 
large nor too retracted. If too large, a feeble child can not draw it. 

The quantity of milk furnished may be judged of by the extent 
to which the breast diminishes in size when the child suckles, and also 
by noticing the degree of distension at the expiration of two or three 
hours after suckling. The trickling of milk from the child's mouth, 
the act of swallowing, and the satisfied manner in which it remains at 
the breast until falling asleep, after twenty or thirty minutes, aid in 



358 Wet-Nurses. 

determining the quantity and character of the milk. A healthy, well- 
developed, and vigorous child of a few weeks, or older, indicates that 
the milk is abundant and of good quality. Still it must be remembered 
that a syphilitic child may present the appearance of health during the 
first few weeks. 

Good human milk has an alkaline reaction, is of a dull white color, 
and has a specific gravity of 1032. 

The diet of the wet-nurse should be generous, and any article 
known to be nutritious, easily digested, and easily assimilated, may be 
allowed. That diet which tends to the preservation of vigorous health 
in the woman, will lead to the formation of the largest supply of nutri- 
tious milk. An excess of meat must not be eaten, if the accustomed 
amount of exercise is no longer taken. Such things as occasional flatu- 
lence or other evidence of indigestion must be avoided. Tea must not 
be drunk in excess. Milk taken during meals is advantageous. An 
increase in the amount of liquids taken tends to increase the amount 
of milk secreted ; but it must be of a nutritious character, such as meat 
broths, gruel made with milk, etc. 

It will rarely be advisable to resort to stimulants. 

The wet-nurse should take plenty of outdoor exercise. The sleep- 
ing apartment should be well ventilated and not too greatly heated. 
The normal action of the bowels must be secured, and abundant ablu- 
tion exacted. The ejiild should sleep in a crib, not with the wet-nurse, 
and the mother should always be on the alert that the wet-nurse does 
not give an anodyne in some form to the infant. 



CHAPTER XXI. 
DIET AFTER WEANING. 

Weaning is the period of infancy when the child is deprived of 
breast milk, and such changes are made in its alimentation as are ren- 
dered necessary by its independent existence. The time of weaning 
can not be fixed at the same age for all infants. Most authorities assert 
that it should take place between the twelfth and eighteenth months. 
Under normal conditions the infant should not be weaned before the 
twelfth month, nor should - lactation be continued after the eighteenth 
month. There is such a general conformity between dental evolution 
and age, that weaning usually takes place at the evolution of the eight 
incisor teeth, which is completed at about the twelfth month. 

Let us assume that the mother has weaned her child at the twelfth 
month, and formulate a dietary accordingly. 

Mothers usually begin supplementary feeding after the eruption 
of the lower central incisors, which is during the seventh or eighth 
month. Very few infants pass far beyond this physiological epoch 
without it. 

During the period of dentition, developmental changes gradually 
take place in the digestive apparatus which fit the child for an inde- 
pendent existence. The glandular structures become more active, and 
the muscular tonicity increases, so that at the period of eruption of 
the anterior molars, the alimentary tract is prepared for semisolid 
food. 

We will prescribe a suitable dietary for a child in health and 
disease, from weaning to puberty. It will be best attained by making- 
divisions to conform to the recognized anatomical and physiological 
changes in the child's organism. The following divisions seem, there- 
fore, to meet all the requirements : — 

1, twelfth to eighteenth month; 2, eighteenth to thirty-sixth 
month; 3, third to fifth year; 4, fifth to eighth year; 5, eighth year to 
puberty. 

Most mothers appreciate the value of milk as the chief food for 
infants during the first year, but very few of them will be convinced 
of its value as such after weaning. Several months before the child 
is weaned, it has had, in many instances, some of the farinaceous food 
and also meat broths. The writer has seen many mothers feed their 
infants from the family table, and they seem to think it a praise- 
worthy method of feeding, teaching their child to cultivate a taste for 
the various foods in early life. 

If weaning takes place before the eruption of the molar teeth, 

(359) 



360 Diet after Weaning. 

the diet should be milk. If the child is weaned during the summer 
months, milk should be its only food, although the molars and, perhaps, 
the canines have appeared. If, however, the child does not seem to 
derive sufficient nourishment from the milk, it should be given addi- 
tional food, provided the weather be cool; but always remember that 
the chief constituent of its diet must be milk. If it seems to thrive on 
milk alone, it will be advisable to limit it to that, until the eighteenth 
month. It is the exception, however, when a child will be satisfied with 
milk until this late period; and if this is the case, some farinaceous 
element, such as barley-water, may be added. The barley-water should 
be ^prepared by grinding a tablespoonful of the grain barley, and add- 
ing six ounces of water, and boiling for fifteen or twenty minutes. 
Salt to suit the taste, after which strain the mixture. This decoction 
should be made twice a day, and kept in a cool place. It should be 
added to the milk in the proportion of one to three or one to two. If 
constipation is the rule, oatmeal may be used, a decoction prepared 
similar to that of the barley. Arrowroot should not be used, on 
account of the large proportion of starch it contains. A small quantity 
of beef juice or curdled egg may be allowed by degrees. To curdle 
an egg properly, the water must be boiling. Let one quart of water 
boil, lift it from the stove, then drop the egg in the boiling water, re- 
cover the vessel, and set it off on the table ; let it stand exactly five min- 
utes ; then lift out the egg, break it into a glass, add a pinch of salt and 
a very little good, fresh butter, or perhaps the child may relish 
it best without the butter. Excellent beef tea is made by mincing 
one pound of lean beef, and adding a pint of cold water and ten drops 
of dilute hydrochloric acid. This should stand for two or three hours, 
with occasional stirring. It should then be left to simmer for fifteen 
or twenty minutes, when it will be ready for use. Beef broth is not very 
nutritious, and it is not recommended. Mutton, veal, and chicken 
broths are more nutritious, and are useful in many cases. It must be 
borne in mind, however, that mutton causes constipation, and veal 
diarrhea. 

Cow's milk is that most generally used for feeding infants. The 
cow should be thoroughly looked after. She may be kept in a badly 
ventilated and foul stable. She may scarcely even run at large, or 
browse, and probably her food will be mainly swill ; though even with- 
out exercise or browsing, if fed on long food and brans, with an occa- 
sional feed of fresh grass, she may furnish a good quality of milk. 
Again, the cow may be a sickly one, but the milkman will not let it 
be known so long as he is receiving his price for his milk. If we are 
sure of getting good, sweet milk, twice a day, from properly-fed cows, 
let us be satisfied! Probably a great many more children would be 
saved if more attention were paid to the preparation and dispensing of 
milk. 

Unmethodical and irregular feeding is quite as bad as feeding 
with improper aliments. The child should be fed regularly with 



Diet after Weaning. 361 

enough milk to satisfy its appetite; but giving it food to appease its 
anger should be positively prohibited. It should be remembered that 
fretful children are usually thirsty, and it is water they crave rather 
than food at irregular intervals. The quantity must necessarily be 
increased as the child advances, but due regard should always be paid 
to its digestive and assimilative powers. Overloading its stomach 
impairs its digestion. 

The most satisfactory result is obtained in securing good, sweet 
milk from a country dairy, delivered twice a day, if possible. As soon 
as it is delivered, pour on the requisite amount of boiling water to scald 
it ; then put it in a refrigerator to be used when required. If there is 
no refrigerator, as is so often the case, it must be kept in a cool place 
after cooling it first by placing the vessel in cold water, keeping the 
milk covered with a clean cloth. Until the fifth month, at least, the 
milk should be given from a bottle to insure steady feeding ; after this 
it may be given from a cup or a glass. 

Do not permit the bottle to be used as a soothing apparatus ; when 
thus employed it does harm. Never let the child sleep with the nipple 
hanging to its lips. It should not be fed oftener than once in four 
hours. With every feeding add a teaspoonful of lime-water, or from 
one-half to one grain of bicarbonate of sodium. When it is through 
feeding, throw away the remaining portion, never allowing it to stand 
in the bottle. Scald the nipples, tubes, and bottle, and keep them in a 
solution of soda until the next meal. The simplest and most convenient 
way of cleansing the bottle is with scalding water with a little baking- 
soda in it, then rinse with scalding water. 

Of the various substitutes for breast milk, condensed milk is prob- 
ably the most extensively used. Very many use it because they can 
not afford cow's milk, and can not spend the time necessary for the 
preparation and preservation of cow's milk, and consequently feed their 
children on this unstable article. The weight of authority is against 
the use of condensed milk, owing -to the lack of nutrient ingredients. 
Children fed with it will grow, but are deficient in muscular vigor. 
Under some circumstances we may be compelled to use it. During 
very warm weather, when poor people can not buy ice to keep cow's milk, 
it may be advisable to use it; but its use should never be sanctioned 
when good cow's milk can be secured. In the country, the cow can 
be kept in a pasture near the house, and the milk can be taken from the 
udder three times a day during the hot season of the year. 

Rotch, in a valuable paper, 1 discusses the merits of the different 
"infant foods," and demonstrates their unreliability as substitutes for 
milk. 

With sixteen teeth the child should be allowed a more liberal diet. 
Its digestive apparatus is now capable of digesting food which has been 
masticated. It may be allowed to have stale, well-cooked bread two or 
three days old, and butter, or crackers. It may also be given a little 

^'Archives of Pediatrics," Vol. 12, No. 44, p. 458. 



362 Diet after Weaning. 

mashed, mealy white potato, well whipped, with gravy. A sandwich 
of scraped lean beef cooked slightly and quickly, seasoned with a little 
salt or a pinch of sugar, will be relished, and is very nutritious. It 
may have a chicken bone to suck, care being taken that it does not 
swallow the pulp or bone. 

In regulating the regimen of a healthy infant during this period, 
very little change is required in its food. It should be fed five or six 
times at the same hours every day, but should not be awakened for this 
purpose. If it desires its food before its accustomed time, it should 
have it. 

First meal, 6 a. m. — A cup of milk with cream biscuit or a slice 
of buttered bread — not stale butter. 

Second meal, 8 a. m. — Stale bread broken and soaked in a tumbler- 
ful of rich, fresh milk. 

Third meal, 12 m.— A slice of buttered bread with about a half a 
pint of weak beef tea, or mutton or chicken broth. 

Fourth meal, 4 p. m. — A tumblerful of milk with crackers, or a 
slice of buttered bread. 

Fifth meal, 8 p f m. — A tumblerful of milk with bread or crackers. 

Toward the latter part of this period, when the child has sixteen 
teeth, it may be desirable to substitute the following : — 

First meal, 6 a. m. — Bread or crackers with a half pint of milk. 

Second meal, 8 a. m. — A tablespoonful of well-cooked oatmeal, 
cracked wheat, or corn-meal mush, with milk, and a couple of slices 
of buttered bread. 

Third meal, 12 m. — Bread and butter, milk, soft-boiled egg. 

Fourth meal, 4 p. m. — A piece of rare roast beef to suck ; mashed 
boiled potatoes, well whipped and moistened with dish gravy. 

Fifth meal, 8 p. m. — Milk and bread and crackers. 1 

This is a modification of the diet laid down by Louis Starr; but 
Adams, M. D., insists that the infant should be confined to milk, milk 
and barley-water, or milk and oatmeal-water, during this entire period. 
He claims that when his advice has been followed, the perils of the 
"second summer" have been avoided. 

A sensible mother can easily choose from the above diet such 
changes as her child relishes, and also such as agree with it. 

Fruits and berries of all kinds should be interdicted. 

Every case of infant feeding must be regulated by its own indi- 
cated requirements. There is no uniform rule applicable to all. Each 
must be studied carefully, and that mode of feeding must be adopted 
which proves best suited to it. The child should not be permitted to 
sit at the family table, provided it is tempted by unwholesome dishes. 
Some children will accept their proper food, where others will not. 

The diet in sickness, during the first period, must be regulated 



•Often it would be preferable to give the fourth meal at 3 p. m., and the fifth meal 
at 6 p. m., especially in winter, so that the child can be put to bed by seven o'clock. 



Diet after Weaning. 363 

bv the nature of the case. It is impossible to prescribe a regimen 
suitable to all sick children. 

Vomiting is the most frequent symptom to be controlled. It may 
be due to overfeeding, or to some fault in the quality of the food. When 
it is caused by overfeeding, a diminution in the quantity of food, as 
well as a longer interval between meals, will usually correct it. If it 
should be caused by a defect in the quality, this should be discovered 
and remedied. If the ejected matter is sour-smelling, the alkali must 
be increased. Frequently forced abstinence will correct it ; and in 
many cases small quantities of food given every fifteen minutes, or 
every twenty or thirty minutes, will have a salutary effect. 

Diarrhea is often the result of improper feeding. The food may 
be too concentrated, or its quality may be poor. When it is due to too 
much solid food, the indicated treatment is to confine the patient to a 
liquid diet. If the quality of the food is not good, it should be 
improved. In many cases the addition of barley-water to the milk will 
prove effective in checking the diarrhea. 

Constipation may often be corrected by adding oatmeal to the 
second meal, or oatmeal-water to the milk, prepared the same as barley- 
water. 

It should be the invariable rule to confine children to a liquid diet 
as soon as any impairment of digestion or assimilation is noticeable or 
they become ill. Milk should always have the preference. It may be 
given pure just from the cow, or diluted, boiled, or perhaps predigested 
in some cases. In rare instances milk will not be retained by the 
stomach, or will be passed from the bowels only partially digested. In 
such cases a mixture of equal parts of milk and lime-water, given in 
teaspoonful doses every ten or fifteen minutes, will frequently be 
retained and digested. In some cases where milk can not be retained, 
barley or rice-water may be temporarily substituted. In other cases 
beef tea, beef essence, or beef juice may be administered in small quan- 
tities, frequently repeated, with marked benefit. Tea and coffee should 
not be allowed. 

To weakly children the following may be given: — 

Chicken Jelly. — Clean a fowl that is about a year old, and remove 
the skin and fat. Chop it, bones and flesh, and put it in a pan with 
two quarts of water. Heat slowly and skim often and carefully, let- 
ting it simmer for five or six hours, when add salt and mace or parsley 
to taste, and strain, and set away to cool. When cold, skim off the fat. 
The jelly is usually relished cold, but may be heated. Give this in 
small quantities very often. 

Wins Whey. — Boil three wineglasses of milk, and add a wine- 
glass of sherry or port wine. Strain and add a wineglass of warm 
water. A wineglassful of this may be given once or twice a day. 

White-Wine Whey. — To half a pint of boiling milk add a wine- 
glassful of sherry; strain through a fine muslin cloth, and sweeten to 
taste. A tablespoonful of this may be given every two or three hours. 



364 Diet after Weaning. 

It is quite as important to regulate the diet during the second 
period as during the first, but much more difficult. At this period the 
child is walking, and often helps itself to indigestible substances. It 
now has all its milk-teeth, and is capable of mastication. Its mind 
is generally sufficiently active to be taught what edible articles it should 
have. Its power of mastication, its flow of saliva, its good digestion and 
assimilation, and its increasing growth, demand a greater variety of 
food. If it reaches the second period during the summer, and has the 
appearance of health, and seems satisfied with its milk, egg, and simple 
food, it will be prudent to wait until cool weather before changing its 
diet to a more substantial kind. 

It is now admissible to allow it to eat at the family table, because 
the opportunity to begin its training early should not be overlooked. 
It can now be taught to eat slowly; that certain articles are not suit- 
able for it; and that it can have enough of the proper kind of food. 
When a child frets for different articles of food on the table, it is gen- 
erally because some imprudent person has allowed it to taste them. If 
it is not tempted by tasting other foods, it will be contented with its own 
simple food. It should be fed at least four times daily, and will occa- 
sionally require a few crackers or a slice of bread and butter between 
meals. 

second period: eighteenth to thirty-sixth month. 

First Meal, 8 a. m. — A portion of well-cooked oatmeal, wheat 
engrits, or corn-meal mush, with a liberal supply of fresh milk, cold 
bread and butter, and a piece of finely-cut, tender beefsteak, or a soft- 
boiled egg. The better plan is to give the egg first, then the mush and 
milk, etc. 

Second Meal, 12 m. — A bowl of chicken or oyster soup or weak 
beef tea; milk, with bread or crackers and butter. 

Third Meal, 4 p. m. — Roast beef, mutton, or turkey; fresh white- 
fish, mashed white potatoes moistened with gravy; bread and butter, 
and rice and milk. 

Fourth Meal, 8 p. m. — Milk, with bread or crackers. 

It may be necessary to give a glass of milk and a piece of bread 
between the first and second meals ; and if the child is particularly 
hearty, the same may be occasionally required in the early morning. 
Toward the latter part of this period fresh ripe fruits are admissible, 
provided due care is taken to prevent the ingestion of seeds and rinds. 
A popular fruit is the banana, but it should be allowed only very spar- 
ingly, as it is more likely to be productive of eclampsia than almost 
any other fruit. 

In the country, children's diet has to be regulated according to the 
local custom. Their heartiest meal is at 12 m. The lightest meal is 
at 6 or 7 p. m. Hence, the child will require a piece of bread and but- 
ter or a tumblerful of milk about 4 p. m. The child will need constant 
watching to prevent it from obtaining unsuitable food. Frequently 



Diet after Weaning. 365 

the neuroses, as eclampsia — "night terrors" — and the numerous symp- 
toms attributed to worms, may be directly traceable to the presence of 
indigestible food in the alimentary tract. Early in the morning, give 
the child a large tumblerful of fresh milk just from the cow. After an 
hour or so, give a brisk purgative, such as sulphate of magnesia, or a 
dose of castor-oil, to move the bowels briskly, and if there are any 
worms you will generally see them. The removing of the excessive 
amount of indigestible food will have a salutary effect on the nervous 
system. 

When the child is suffering from acute disease, its diet should be 
limited to milk and beef tea. In chronic ailments or in protracted 
convalescence from acute disease, each case must be treated according 
to its individual requirements, while good judgment will render valu- 
able assistance in the selection of those foods which are easily digested, 
and which possess the maximum quantity of nutritious matter to the 
quantity ingested. Do not give a sick child tea and toast ; it only loads 
the stomach with innutritious matter. 

In the country, chicken, eggs, and fresh milk are always obtain- 
able in the summer season, because of the hot weather. Chicken- jelly 
and eggs will take the place of beef juice and beef tea. 

THIRD PERIOD: FROM THE THIRD TO THE FIFTH YEAR. 

During this period the difficulty of regulating the child's diet will 
be very great. It has now reached the age when its friends will humor 
it with knickknacks and table food of difficult digestion. It has twenty 
teeth, and its friends can not understand why it should not have such 
food as a healthy adult can digest. A devoted mother will reason thus, 
or usually a grandmother will argue that all her children at this age 
were fed from the table, and were not injured. Such children lived in 
spite of mismanagement. Granting that the child's diet must be more 
liberal at this age, it still must be restricted, for even now the presence 
of indigestible or undigested food in the alimentary tract may be pro- 
ductive of reflex nervous disturbances. 

Its activity and waste and repair demand an increase in the quan- 
tity of nutritious food. Three substantial meals a day will usually 
suffice, with occasionally a piece of bread and butter between meals. If 
the child is hungry between meals, it should not be made to wait until 
the next regular meal, as it may suffer from hunger. A "snack" is 
necessary for the welfare of the child. The practise of children run- 
ning to the pantry between meals should not be allowed. Let the 
mother or nurse give them the necessary amount to obviate hunger till 
the regular meal-time. Where children are allowed to help themselves 
from the pantry between meals, they do not eat enough at the regular 
meals. 

It is impossible to lay down a "bill of fare" for this period, but a 
frugal meal can be selected from the following: — 



366 Diet after Weaning. 

Breakfast. 

Corn-meal mush, oatmeal, wheaten grits, hominy, with plenty of 
cream. Potatoes, baked or stewed. 

Eggs, poached, soft boiled, or an omelet. 

Fish, fresh broiled. 

Meats, beef hash, broiled steaks, stewed liver, lamb chops, and 
chicken fricassee. 

Tomatoes, sliced (occasionally). 

Bread, cold, light; graham gems (occasionally); corn and rice 
cakes, with a little syrup. 

Fresh ripe fruit may be given in moderate quantity. 

Highly-seasoned food must be avoided. 

Luncheon. 

Soups: Oyster, bean, chicken. 

Vegetables: Potatoes, baked or stewed; sliced tomatoes. 

Meats: Beefsteak, lamb chops, cold lamb, or mutton. 

Bread: Cold rolls and soda crackers. 

Fruit in season. 

Bice and milk. 

Dinner. 

Soups: Noodle, oyster, cream-barley, potato, chicken, or chicken 
stew. 

Fish: Fresh, baked, boiled, or broiled. 

Meats : Beef, chicken, lamb, or mutton. 

Vegetables : Potatoes, cauliflower, peas, tomatoes, and beans. 

Bread: Wheaten, well-cooked. 

Desserts: Bice and milk, light puddings, ice-cream (occasionally). 

Fruits and berries in season (fresh and sound). 

Desserts for children after two and one-half years may be: Plain 
custard, ice-cream (not oftener than once a week), rice pudding (no 
raisins) $ baked apples (with or without cream), stewed prunes, molasses 
ginger cake, currant or apple jelly. 

The regimen of the sick during this period does not differ very 
materially from that of the preceding, except that, generally, a more 
generous diet may be allowed. If the illness is of a nature demanding 
liquid food, the principle already set forth will be applicable. In cases 
of illness the food should be reduced in quantity and changed in char- 
acter, although the patient may not be confined to liquids. As soon 
as the appetite becomes impaired, the child should be put upon a sim- 
ple diet. Frequently, in children of this age, too much deteriorated 
fruit will cause digestive disturbances. Withholding the fruit a few 
days will effect a cure. The child should always have its fruit selected 
for it, and it should be of the choicest quality. When sick, knickknacks 
and fancy dishes should be forbidden. If the illness be protracted, and 
the food be digested and assimilated, it should have the most nutritious 
aliment. This rule is especially applicable to scrofulous, syphilitic, 



Diet after Weaning. 367 

rachitic, and tuberculous children. We need not wait for a manifesta- 
tion of these diatheses. If there is good reason for suspecting their 
presence, the sooner the select diet is begun the better ; and, even if they 
are not latent in these children, the care in feeding will prove beneficial. 

New troubles seem to arise during the fourth period which 
require close vigilance over the child's dietary. This period extends 
from the fourth to the eighth year. At this time the milk-teeth begin 
to decay, and the first of the permanent teeth make their appearance. 
The child has frequent attacks of toothache, the dread of which pre- 
vents it from properly masticating its food. Consequently, indigestion 
and diarrhea, from bolting food, are of frequent occurrence. 

Again, the child is old enough to be indulged by its parents in 
everything they eat ; hence, the possibility of restricting the diet as long 
as it is healthy. 

It is advisable to select its food from the articles recommended for 
the third period, with the addition, perhaps, of game, corn, string- 
beans, sweet potatoes, Lima beans, hot bread and cakes, and light cus- 
tards and puddings. In sickness, the general rule of restricting the 
diet according to the nature of each individual case is also applied. 

The physiological changes which take place during the fifth period, 
which is from the eighth year till puberty, would warrant the statement 
that the most extraordinary care should be exercised in regulating the 
child's regimen. 

The ingestion of too highly-seasoned or too rich food, it is said, 
may unduly excite the passions and pervert the physiological phenomena 
of boyhood and girlhood. It is also apt to cause lascivious dreams, and 
probably sexual excitement. 

The rules governing the dietary during sickness are similar to 
those for adults. 

The use of wine and beer should be entirely prohibited, and that 
of tea and coffee discountenanced. 

In discussing the diet for children, some regard must be paid to the 
important factor of the circumstances of life. In presenting a regimen 
of diet which has stood the tests of the laboratory, we must remember 
that such advice is given to a large number who are not able to incur 
the necessary expense of typical feeding. To prescribe such food as 
that heretofore mentioned, and recommend it for the child of the 
laborer whose wages are scarcely adequate to support his large family, 
would entail hardship on those whose affections are strongest for the 
weak and afflicted. The expense necessary to obtain cream, milk, and 
milk-sugar will not be considered by people of even moderate circum- 
stances ; but it will be difficult for the mechanic, and impossible for the 
laborer. Therefore, it is important in selecting a food for children, 
either well or ill, in the lower walks of life, to recommend that which 
will be healthful and of reasonable cost. 

If the following good advice is impressed upon the mother 
or nurse, the success of treatment may be greater : — 



368 Diet after Weaning. 

"Never give recooked meats, fish, or vegetables to an invalid, and 
cook only small quantities for the child. Simplicity, variety, and 
healthfulness are the things to be considered in preparing food for the 
sick. The vessels that the food is cooked in should be thoroughly 
clean. What is good for one person is frequently injurious to another. 
One must not become impatient or discouraged because the invalid 
is changeable in his tastes." 

The eye as well as the palate of the patient is to be 'considered. 
The tray should always be covered with a fresh napkin. The china, 
glass, and silver should be the daintiest the house affords. Only a 
few things should be served at a time. It is better that the patient 
should think that he has not had enough to eat than that he should lose 
his appetite on the appearance of too large a quantity of food. The 
patient should be served first, and not be made to wait till the family 
have finished. 



CHAPTER XXII. 
JSTUESEEY HYGIENE. 

Nursery hygiene in its full sense includes the same topics and 
covers the same ground as does general hygiene, with "such variations 
as to details as are required by the ages of the occupants of the nursery. 

The subject of the new-born will be discussed in the chapter on 
maternity. The feeding of the young and dentition are discussed under 
their respective headings. This present chapter will be restricted to 
suggestions concerning the nursery itself, its situation and surroundings, 
its warming and ventilation, nursery nuisances and their avoidance, 
the dress, bath, and toilet of children, and care of their food. We will 
quote from different authors, adding our own experiences. 

While it is true that as regards many of these topics medical 
advice is rarely asked, it is also true that to the mass of persons the 
family physician is the only sanitary authority, and that by opportune 
suggestions he may do much, in the aggregate, in the way of prevention 
of disease. However much such guidance may be necessary in gen- 
eral, it is still more imperatively demanded in nursery matters, owing 
to the exaggerated susceptibility of young children to the depressing 
influences that affect their development. It seems proper, therefore, 
to call attention, even at the risk of insisting upon truism, to details 
which are often relegated to the discretion of nurses. 

Of course no nursery can be thoroughly healthful unless the house 
itself is such, — is well placed upon good soil, and so constructed in 
detail that the rules of sanitation have been consciously or unconsciously 
considered. These rules we can not discuss. It will be assumed that 
the house is as well situated, as well drained, as well built, and as 
well lighted as the means of the owner will allow. The details which 
follow are such as will assist in making the nursery the most healthful 
part of a good house, and as wholesome as practicable in a defective 
one. 

In selecting a room for a nursery, that one should be chosen which 
is the sunniest, best aired, and driest ; and in deciding between two or 
more houses in other respects eligible, distinct preference should be 
given to that one admitting of the best arrangements for nursery pur- 
poses. In houses where no room is to be set apart especially as a 
nursery, and children are to occupy the general living-room by day and 
the parents' bedroom at night, the same rules should govern the selec- 
tion of these rooms, the sanitary benefits in such case accruing to adults 
and children alike. When possible, it is preferable to place the nursery 
above the ground floor, unless the latter is unusually well raised from 

24 (369) 



370 Nursery Hygiene. 

the ground ; but it should not be immediately under a roof, on account 
of the difficulty of regulating the temperature in such a situation. 

Every one should know the beneficial influence of sunlight. Its 
healthfulness needs no insisting upon. Nevertheless, it is constantly 
overlooked. The nursery should, if possible, look to the south, or as 
nearly so as the situation of the house will permit, with a morning 
exposure in preference to an afternoon sun, if but one can be had. 
The windows should be ample in size, and more than one if possible, as 
they not only serve for the admission of light, but in the ordinary 
dwelling are the only means of ventilation. The sensibility to the 
loss of sunlight seems to vary somewhat with adults, but we believe 
that all children suffer from its absence, and the daily complete sunning 
of the apartments should be insisted upon. 

In summer, even, it is usually better to have the sun and to miti- 
gate its power at proper times by means of awnings and blinds, than 
to have a room upon which it does not shine. There may be circum- 
stances of climate or of prevailing winds which will modify this rule, 
but it holds in general. The room should be of ample size, particularly 
if it serves, as is the rule in ordinary houses, the double purpose of 
night and day nursery. a The precise amount of space required for 
each child will vary with the arrangements for ventilation ; but not less 
than fifteen hundred cubic feet of air per hour should be allowed, and 
preferably double that amount." 

As only in the houses of the wealthy can a room be specially set 
apart as a sick-bay or a hospital, the nursery must ordinarily serve that 
purpose whenever illness occurs. For this reason, as well as for others, 
the furnishing of a nursery should be as simple and as easy of cleaning 
as possible and be consistent with comfort. The floor should be of 
smooth, closely- jointed boards, preferably hard, close-grained wood. 
The seams, if they open by shrinkage, should be closed, either by relay- 
ing, or by calking well done. Poor calking is worse than useless, and 
any calking is inconvenient in rooms the floor of which must be raised to 
reach gas or water-pipes, as is unfortunately the case. Carpets are nec- 
essary to comfort, but movable carpets or rugs are far preferable, as per- 
mitting more frequent cleaning both of the carpet and floor. In a warm 
climate a bare floor is still better. It may be painted and varnished. 
At the present time even cheap grades of carpet are made in rug form, 
or the desired pattern can be made up with tasty borders without much 
expense. In cases of actual illness of a contagious nature, the rugs 
may be taken away at once, and their contamination be prevented, which, 
in view of the difficulty of subsequent disinfection, is very desirable. 
The same precaution against dangerous dirt leads to the preference, for 
the nursery, of painted and varnished walls to those papered, even at 
the loss of some beauty in the apartment. If paper is strongly insisted 
on it should be of a kind that can be thoroughly varnished, and will 
admit of being washed, and all old paper must first be removed before 
new is laid. 



Nursery Hygiene. 371 

The furniture of the room should be as light as is consistent with 
serviceability, in order that the pieces may be easily moved from place 
to place to admit of frequent cleansing ; and for the same reason every 
bulky or heavy article should have large and strong casters. It is 
further desirable that all furniture should be as plain and simple as 
possible, carved wood and thick upholstery stuffs being objectionable 
as receptacles for dust. Taste may be gratified without violating this 
requirement. Further, all cupboards, closets, and similar places of 
deposit should be as open to inspection as possible, in order that offen- 
sive or untidy things may be easily detached and removed. On 
account of this facility of examination and cleansing, the writer usually 
prefers shelves with movable curtains in front, to closed cupboards and 
deep drawers. The deep drawers are suitable enough for clean linen, 
but are a temptation to careless attendants to indulge in a tuck-away 
neatness.' 7 

Warming and ventilation will only be touched upon in this article. 
If the nursery is in a house with a good system of heating and ventilat- 
ing, nothing in particular will be needed except a grate or a stove for use 
in emergencies. Ordinarily, however, even houses which have a fairly 
good furnace or other heating apparatus have no specific arrangements 
for ventilation beyond what are afforded by the windows, chimneys, 
and imperfections of structure. The ordinary methods of warming 
in use in this country are open fires, stoves, and furnaces. The hot-air 
furnace, if properly constructed, is quite satisfactory. Its commonest 
faults are the delivery of too small a quantity of air at too high a tem- 
perature (a larger quantity at a lower temperature being preferable), 
and such arrangements of its cold-air flue that the supply is from an 
impure source. The former difficulty is overcome by having the fur- 
nace considerably larger than necessary, and by keeping the fire mod- 
erate. The latter, by using a tight metal flue, the outer end of which 
is free from unwholesome surroundings, and properly raised some feet 
from the ground, by which means some of the foul air of dark city 
back yards or of the gutters is avoided. The same precaution is of 
use in many country houses. The outer end must be protected by wire 
screen to prevent mischief being done by children or small animals. 
If the screen is fine-textured, it will diminish the amount of dust 
drawn into the house. For a nursery, it is of advantage to have the 
registers for warm air rather high, as this arrangement makes a better 
general circulation of air, diminishes the intensity of floor draughts, 
and renders meddling with the register by small children more difficult. 

The open fireplace has for advantages cheerfulness of aspect and 
a fair amount of ventilating power ; for disadvantages, great wasteful- 
ness of fuel in proportion to its heating power, so that ordinarily, when 
this is the only source of heat, great differences of temperature exist in 
different parts of the room. If the neighborhood of the fire is com- 
fortable, the remote parts are cold. Further, it ventilates by the pro- 
duction of draughts, particularly floor-draughts, which are especially 



372 Nursery Hygiene. 

dangerous in the nursery, where little children spend so much of their 
time upon the floor. The wood fire is very beautiful and useful when 
a short, quick heat is needed; but aside from its costliness it is not so 
good for heating as a steady coal fire. In a nursery, any open fire 
must be guarded by a strong wire screen, to prevent accidents from 
sparks, or from the clothing of children taking fire. Stoves of the 
ordinary closed variety, the "air-tight," are very economical of fuel, but 
nearly useless as ventilators, and, if used, make especial watchfulness 
as to ventilation necessary. The ventilating stoves, which are the 
offspring of the old Franklin, make a compromise by which all the 
verltilating value of the open grate is preserved with less waste of fuel, 
about three times as much of the heat value of a given amount of fuel 
being utilized by these stoves as by the open fire. The principle of 
construction in its simplicity is to surround the stove and its smoke 
flue for some distance with an air chamber ; to this chamber is admitted 
air, preferably from out-of-doors, and as it is warmed it is poured into 
the room at a higher point, for instance near the mantel. As regards 
all stoves, it is perhaps safer to have no damper in the smoke flue, or 
else to fasten it so that it can not be closed without difficulty, since by 
doing so the danger of gases of combustion being forced into the room 
is removed. 

The stove used in barracks seems to be well adapted for nursery 
use. It is surounded by a jacket of sheet-zinc or iron, with the neces- 
sary doors, leaving space between the stove and the jacket. This should 
come to the floor, and the cold air be brought from out-of-doors to 
within the jacket by means of a small pipe, the warm air escaping at 
the top of the jacket. For the nursery the jacket has the advantage 
of being a safeguard against burns, at least against severe ones. 

The getting rid of foul air is a more difficult problem, especially 
with stove heat. An open window with the double current, that is, 
down from the top a short ways, and up from the bottom, the "elbow 
ventilator" placed under the lower sash, is well known ; so are various 
wire screens, either vertical or rotating like a transom. These do 
fairly well under favorable circumstances, but are rarely sufficient 
when air-tight stoves are used. If in the construction of chimneys a 
ventilating flue is included, or if the smoke flue is inclosed in a space 
which may serve as a ventilating flue (as, for instance, a stovepipe run- 
ning up within a chimney which has a fireplace at the bottom), it is 
easier to ventilate a room. If the chimneys are already closed in, the 
cheapest and at the same time an efficient method is to have an air 
flue leading from near the floor into the chimney higher up. The 
upward current of air in the latter draws the air through the ventilat- 
ing shaft. It is more efficient if placed near the stove, so that the air 
within it is heated and its upward movement hastened. Its mouth is 
placed low so as to save unnecessary waste of warm air. 

It should be remembered that artificial lighting by lamps or gas 
rapidly spoils the air in a room for breathing. Lighting capacity is 



Nursery Hygiene. 373 

usually measured in candles, and an average adult produces rather 
less than twice as much carbonic acid as one candle. A large kerosene 
lamp or a gas-burner often equals the production of five or six adults. 
It is very desirable, therefore, if a night-light is necessary in the 
nursery, that its carbonic acid be got rid of, and by the device often 
used for ventilating purposes, of putting the burner or lamp within or 
beneath a tube or flue going to the roof or chimney, the result of com- 
bustion is carried away, and an outward current of small power is also 
established. By having at the bottom of the flue a box, with a door, to 
contain the light, the latter may be shut off partly or wholly except when 
needed. 

As to the temperature of nurseries, authorities are not quite 
agreed. We believe that if a room can be uniformly heated 65 degrees 
Fahrenheit, it will be found, on the whole, more comfortable and 
healthful than the usual 70 degrees Fahrenheit, which latter should 
not be exceeded. At night the temperature should not be allowed to 
fall too far below the day standard, and special pains should be taken 
to guard against the uncovering of children in bed. 

A word concerning windows. As is well known, the loss of heat 
from the cold glass is very great. Mr. Hood puts it that by each square 
foot of glass more than one and a quarter cubic feet (1.279 cubic feet) 
will be lowered each minute as many degrees as the difference between 
the internal and external temperatures. If, for instance, the ther- 
mometer outside showed no colder than freezing temperature (32 
degrees Fahrenheit), and within no higher than 67 degrees Fahren- 
heit, the discrepancy would still be 35 degrees. A window three feet 
by six feet would expose eighteen feet of glass surface, and according 
to this rule, it would cool each minute 18x35x1.279, equals 805 cubic 
feet, one degree, or about two hundred cubic feet four degrees. This 
makes a constant current of cold, descending air near a window, very 
sensibly felt by any one obliged to work in such a place in cold weather. 
It is important, then, that children should not play near a window in 
cold weather, and a low article of furniture may often be so placed as to 
keep them away without the trouble of constant oversight. The 
ingenuity of the attendant will similarly devise means of keeping them 
from sitting on the floor if it be draughty. 

Besides the admission of pure air and the discharge of foul air, 
purity of atmosphere demands that no nursery nuisance be allowed to 
exist. It is better that no plumbing of any sort should be in the room 
itself. Bath and closet conveniences are very necessary, but should 
be a little removed and well ventilated. In houses that are not 
plumbed, a place to which all offensive or soiled articles can be directly 
removed should be provided, which place should have free ventilation. 
All soiled napkins, and vessels containing evacuation or urine, should 
be promptly removed, and in case of sickness a vessel should be pro- 
vided in which the napkins or stools can be disinfected. 



374 Nursery Hygiene. 

Under ordinary circumstances, however, disinfectants, in the nsual 
sense of the word, have no place in the nursery nor in hygiene generally. 
A place that can not be made wholesome by sunlight, air, and cleanli- 
ness should not be occupied. Whenever emergencies demand their use, 
and after a contagious illness, only the more costly contents of the 
nursery should be disinfected; the cheaper ones can be burned with a 
greater ultimate economy. For this reason the toys should be of the 
cheaper variety, particularly if of such a kind as readily to conceal 
supposed sources of contagion. The painting of walls and ceilings, and 
the closely-laid floor, already urged, are of great assistance in promoting 
efficiency of disinfection. 

Toilet. — The bath has many uses as a remedial agency, both in 
lessening temperature and in quieting nervous irritation of various 
sorts. It is here considered only in its hygienic uses as a part of the 
toilet. The object of baths thus employed is simply cleanliness and 
the aiding of the proper functions of the skin, with practically little 
intent to produce the stimulating effect incident to the cool morning 
bath. Such a bath needs to be of a moderately high temperature ; that 
is to say, not very much below the usual skin temperature, so that 
no great effect shall be had upon the general system. By using warm 
water, moreover, a smaller amount of soap and friction is necessary for 
cleansing, both of which in excess tend to irritate the delicate skin of 
the infant. Only the best, purest, and blandest soaps should be used. 
While undue coddling is to be avoided, all "hardening" or "toughening" 
regimen is distinctly pernicious in infancy, and should be used with 
judgment according to individual constitution throughout the develop- 
mental years. The power of a bath at a given temperature (according 
as the effects of a hot bath or a cold bath are sought) is much greater 
when the body is immersed than when it is sponged for the same length 
of time. For this reason, in children at all feeble, the immersion 
should be brief or omitted altogether. The bath should never be 
allowed to become a domestic fetish, but its object should be kept in 
mind, and its results noted. For young infants in ordinary health, the 
method of administration followed by intelligent nurses is entirely 
satisfactory. The bath-tub contains water at about 95 degrees Fahren- 
heit, which may cool a few degrees during the operation. The child, 
lying upon the bath-blanket spread upon the nurse's lap, is sponged 
with soap and warm water, particular attention being paid to those 
parts most likely to have sebaceous accumulations or to be otherwise 
soiled, such as the scalp, armpits, groins, and seat. This done, the 
child is dipped into the bath for simple rinsing, laid in its blanket, and 
dried with it without rubbing. As it grows older, its back is supported 
by the hand of the nurse, and it is allowed to frolic in the water for a 
few minutes, the exercise of kicking and its pleasure insuring a healthy 
reaction after the bath. If a child is alarmed at its bath, the immersion 
should be omitted or be very brief, as fright will counteract any benefit 
from the immersion, and may often be accepted as evidence that from 



Nursery Hygiene. 375 

some cause the procedure is unsuitable. If it enjoys the bath, its 
immersion may be gradually prolonged, and the temperature some- 
what diminished, say to 85 degrees Fahrenheit. 

Toilet powders are not necessary. Their purpose is only to dry 
the skin. (However, the powder feels comfortable.) This is better 
done by careful pressure with soft cloths with little friction. If irri- 
tation exists around the seat or in the groins, or in other places where 
moisture is usually excessive, powder is useful. We prefer mineral 
to vegetable powders, on account of their freedom from fermentive 
changes. Powdered talc we think the best. 

If a cold bath is to be used for its stimulating effect upon a young 
child, before the full bath, the bath by affusion should be tried, the 
child standing in a tub while water is applied by squeezing it from a 
full-sized sponge. 

The shower and douche-bath have no place in the nursery except 
as therapeutic resources. 

Neither the indoor nor the outdoor bath should be given soon after 
a meal, nor when the child is really hungry. In the one case indiges- 
tion is likely to follow; in the other, the shock of the bath is not well 
reacted from. 

For very young children, sea bathing, unless ordered by your 
family physician as a remedy, is rarely desirable. As soon as the 
child is old enough to comprehend the method, it should be taught 
how to swim. 

The care of the hair in infancy consists chiefly in the care of the 
scalp, which must be kept strictly clean. A soft brush should be fre- 
quently used upon the hair ; a comb only as a separator for parting the 
locks and in emergency for disentangling. The teeth require the 
same care as in adult life, but brushing should be of the gentlest sort, 
for fear of irritation of the gums, which may cause their subsequent 
retraction. In infancy, after each feeding or nursing, the gums should 
be washed to prevent the formation of aphthous growths, and the teeth 
treated likewise as they appear. When the child is old enough to be 
quiet while the cleansing is done, a soft badger-hair toothbrush should 
be used. 

Dress. — The hygienic essentials of dress are sufficient warmth 
without burdensomeness, uniformity of protection as far as consistent 
with activity, freedom, and, for children at least, softness. Woolen 
garments are preferred, because of the warmth without undue weight. 
Owing to the poor conducting power of wool, such garments retain the 
heat longer than those made of other materials. This slowness of conduc- 
tion is greater in loose-textured fabrics. That is to say, a given weight 
of wool is warmer if loosely than if tightly woven. Hence, the warmth 
of knitted garments. The difference is due to the retention in the 
interstices of a certain amount of air, which is a poor conductor. For 
the same reason, two garments, two shirts for instance, are warmer 
than one shirt of equal weight to the two; and loose-fitting garments 



376 Nursery Hygiene. 

are warmer than tight ones. In hot weather, however, tight-fitting 
garments are distressing for other reasons. 

Linen stands at the other extreme of ordinary dress material, 
being the best conductor of heat. It follows that woolen garments 
give the best protection against the change of temperature and chill- 
ing; and in proper weight they make the safest dress in all places 
where the temperature may vary, or for all children who may become 
heated in play. Fashion or taste usuallv calls for outer garments of 
linen, but the protective garments should be beneath. The absorption 
from the sun varies much according to the color of the garment, the 
material and texture being unchanged, white taking the least heat, or 
being the coolest, while black will absorb about twice as much. Sin- 
gularly enough, the "cool-looking" light blue is found, by experiment, 
to be nearly as hot as black. For very young children, who are little 
exposed to the sun's heat, this question of color is of minor impor- 
tance. 

Softness of material is essential for children on account of the 
sensitiveness of their skin. To most infants, fine, soft woolen shirts, 
either knitted or of baby flannel, are seemingly entirely comfort- 
able. Some, however, manifest unusual irritability of skin, and such 
a shirt of fine linen should be placed within the flannel. This pre- 
caution is more often necessary in hot weather, when the flow of 
perspiration is increased. 

The ordinary dress for very young children is objectionable in 
several ways. It is usually unnecessarily confined about the body and 
limbs, although it has never in this country reached the degree in this 
respect that seems to be usual in some countries. There is also an 
unnecessary number of layers of fabric involved, as they are not 
requisite for the child's warmth under ordinary circumstances. The 
process of dressing or undressing is really an ordeal to the infant, as it 
is alternately rolled upon its back and belly in the nurse's lap, in order 
that one band after another shall be fastened by pins or stitches. Very 
much of this dressing is unnecessary, if not harmful. First of 
all is the "band," a girdle enveloping the trunk from about the nipple 
to the iliac crest. Such an appliance is useful during the healing of 
the navel ; afterwards it is not of use if tight. The abdomen needs no 
support in health, and the compression of the ribs is not advantageous, 
and so far as such a girdle affects the question of hernia (which it is 
popularly supposed to prevent), it is thought it rather favors the pro- 
duction of the inguinal variety. A loose girdle worn to prevent chill- 
ing is advisable in hot weather, and in cold weather a flannel girdle 
or binder, cut bias to secure elasticity, makes a useful envelope for 
the entire trunk of very young children as a preventive of bronchitis. 

As a means of getting rid of the objectionable feature of the 
ordinary dress, the following plan was originally devised by Dr. 
Grosvenor, of Chicago, for use in his own family, and subsequently 
published by him. There are three garments, besides the napkin, all 



Nursery Hygiene. 377 

covering the neck and shoulders, reaching about ten or twelve inches 
below the feet. The outer garment, as well as the middle one, is a lit- 
tle larger in every dimension than that beneath it, so that no binding- 
shall take place. They are all cut in the girdleless pattern called 
Princess. The inner one has sleeves, and may be made of cotton 
flannel or very soft wool flannel. If wool is used, care must be taken 
against shrinkage in washing. The next garment has no sleeves and 
seams at the armholes, to insure against pressure there. The material 
is wool flannel. The outer one is the usual dress, with high neck and 
sleeves, the details of which may be modified to suit the taste. Thus, 
except the sleeves, the thickness is the same throughout. At night a 
garment like the inner one above described and a napkin only are 
worn. These three garments are placed one within the other before 
commencing to dress the infant, pains being taken to avoid wrinkles 
and folds, and they are put upon the child as one garment with very 
little trouble. They are removed with equal ease. 

The napkin may be made of any suitable kind, i. e., soft and 
absorbent material, ' easily washed. Linen has no real advantage ordi- 
narily over cotton, except aesthetically. Old linen is soft, but likely to 
be thin. It is desirable to diminish the bulk of napkins as far as 
possible, to prevent uncomfortable pressure. This is accomplished by 
having a small napkin simply to cover the seat and genitals thick 
enough to retain the urine and fasces, covered by another one not thick, 
but large enough to envelop the hips. The age at which napkins may 
be discontinued depends upon circumstances. Among English fam- 
ilies of the better classes, apparently, children are taught to make 
their needs known earlier than is usual with us. Much can be done 
by an attentive nurse or mother who will hold the child over a vessel 
close to a warm fire. The heat will cause the child to urinate, and 
immediately after, cover the child up, and it is surprising how quick it 
will learn when thus exposed for what purpose it is done. In the 
same manner, at stated times, their bowels can be made to move. But 
children vary greatly in this particular, and under no circumstances 
is any severity justified, or even scolding, as nervousness or anxiety 
on the part of the child simply aggravates the trouble. As soon as the 
child can regularly give notice of its wants in this respect, it is time 
to discontinue the diaper, as its absence gives greater freedom of the 
limbs. Of course at all times napkins should be changed as soon as 
discovered to be damp or soiled. Rubber or other impervious covers 
for diapers should not be used. Even the exigencies of a railway 
journey, with the conveniences usual in this country, do not require 
their employment. They simply convert a wet napkin into an unclean 
fomentation. When a child begins to use its limbs freely, the clothing 
should be shortened. In fact, there is no real need of long clothes at 
any time, except to save labor in keeping the infant's feet covered. 
When it begins to creep, its maneuvers are facilitated by slipping over 
its skirts a loose pair of baggy breeches of woolen, which should be tied 



378 Nursery Hygiene. 

around its waist and buttoned about the knees. This keeps the skirts 
from impeding its progress, and protects it against floor draughts. 

The dress of older children should conform to the same hygienic 
requirements as given above. The two most frequently discarded are 
freedom from constriction and uniformity of protection. The former 
is violated by the use of tight girdles, or even corsets, tight sleeves, 
garters, and misshaped stockings and shoes. Their harmfulness is 
well understood. The neglect is usually a wilful preference of fashion 
to healthfulness. The same might, perhaps, be said of the fashion of 
unevenly distributing the clothing over the person, but the injurious 
effects of this are less understood. Chilling is resisted far better if 
the whole person is exposed to the same temperature, than if one part 
is exposed to a lower temperature than another. 

It is a matter of universal experience that many persons who rejoice 
in outdoor life, even in severe weather, are directly injured by a draught 
and by sitting near a window. Yet formerly more than now low-necked 
dresses were used for children, the entire shoulders being exposed, 
while the remainder of the trunk was burdened with dress. At the 
present time fashion exposes the legs more. Shoes and stockings are 
often too thin ; but in particular children are too often dressed with the 
lower limbs bare from above the knees to a little above the ankles, the 
foot being covered by a slipper. This fashion seems to be more com- 
mon in Europe than in America. The lower limbs should be thor- 
oughly clad, not cumbrously, but warmly. The stockings of a child 
old enough to run about should be long enough to meet or be overlapped 
by the next article, napkin or drawers, as the case may be. Stockings 
of wool, for the reasons already given, are to be preferred. They 
should be soft. They should not be pointed at the toes, but be wide 
enough to admit of ample play in every direction of the anterior part 
of the foot. Color is not indifferent, as some dyes have been found 
to produce eruptions on the skin. Public attention has, however, been 
so thoroughly drawn to this subject as to have led in some instances 
to legislative enactments, and such dyes are probably less frequently 
used than formerly. Aniline reds have been thought to be especially 
irritating. 

Shoes of proper shape are not so easy to get for children , not 
nearly so easy as for adults. This comes probably partly from the 
supposed necessity of making them for a low price, and partly from a 
belief, often openly expressed, that a "baby's foot has no shape." It 
is not enough that a shoe should be as wide or wider than the foot, but 
it should have its width rightly disposed. The space where the foot 
does not demand it in nowise compensates for pressure elsewhere. The 
result must evidently be a distortion. In choosing shoes for infants 
it is better that they should be unduly long, if that be necessary to 
obtain the requisite width in front, than that they should be narrow. 

The care of food has been treated of elsewhere. 



Nursery Hygiene. 379 

To the care of drinking water the same general rules of cleanli- 
ness apply as to the care of food. But if the supply of water is not 
good, the consumer is usually less able to remedy the difficulty than he 
is in the matter of food. 

If water is too hard, it can be improved somewhat by boiling, 
which causes the deposit of part of the lime. If the water is impure 
from organic matter, the impurities may or may not be deleterious to 
health. Water from ponds is often high-colored, and even at times 
disagreeable in odor from vegetable matter without any mischief fol- 
lowing its use. We have known typhoid fever resulting from the use 
of well-water where there were contaminations from privies, although 
the well-water seemed to the eye and the nose to be pure. Perfectly 
efficient niters which yield any considerable amount of water (porcelain 
filters, etc.) are too costly for general use. But water can ordinarily 
be made safe by thorough boiling for fifteen or twenty minutes, but 
better still by boiling two successive days and subsequent coarse filtra- 
tion through filter paper or a wad of absorbent cotton packed neatly 
into the bottom of the funnel. The entire outfit of a large funnel and 
a water-vessel costs but very little. It may be of tin if constantly 
watched and cleansed. 

The use of iced water is undesirable, for various reasons. The 
ice may be impure, and freshly-made iced-water is not proper for 
children's consumption. Both difficulties may be overcome by putting 
the household drinking water into large corked bottles or into glass 
jars, and placing them near the ice or in the refrigerator. In this way 
water may be had that is cooler than ordinary spring water and safe 
to drink. If the taste of water that has been boiled seems insipid, as 
it is apt to do at first, the addition of a minute quantity of salt gener- 
ally renders it palatable. 

Outdoor Exercise. — Except in inclement weather, most children 
are better for being out daily to receive the influence of the sun and 
the pure air. Of course exceptions 'exist, particularly in winter. Chil- 
dren may be wrapped up when the room is thoroughly aired as often 
as necessary during the day, when the weather is inclement, and they 
can not be carried out without exposure to the cold. 



CHAPTER XXIII. 
DENTITION. 

Definition. — The term "dentition," as generally used, refers only 
to that stage of development when the tooth is penetrating the super- 
ficial tissues of the gum. The period between the seventh month, when 
the first teeth appear, and the end of the second year, at which time the 
second temporary molars erupt, is spoken of as the dentition epoch. 

By the second dentition is meant the eruption of the permanent 
teeth. 

"The germs of the milk-teeth make their appearance in the follow- 
ing order : At the seventh week, the germ of the first molar of the upper 
jaw appears ; at the eighth week, that of the canine tooth is developed ; 
the incisor papillae appear about the ninth week (the central preceding 
the lateral) ; lastly, the second molar papillse appear at the tenth week, 
behind the anterior molar. The teeth of the lower jaw appear rather 
later, the first molar papillse being only just visible at the seventh week, 
and the tenth papillae not being developed before the eleventh week." 1 

ERUPTION OF THE TEETH. 

Between the sixth and eighth months after birth the two lower cen- 
tral incisors erupt, usually simultaneously. 

Between the eighth and tenth months the two upper central incis- 
ors appear, followed shortly by the two lateral incisors. 

Between the twelfth and fourteenth months the two upper anterior 
molars, the two inferior lateral incisors, and the two lower anterior 
molars appear, in the order mentioned. 

Between the sixteenth and twenty-second months the four canine 
teeth erupt. 

Between the twentieth month and the end of the third year the 
four posterior molars erupt. 

The eruption of the twenty milk-teeth is now complete, and no more 
teeth appear until the fifth or sixth year, when the eruption of the 
permanent teeth commences. 

SHEDDING OF THE DECIDUOUS TEETH. 

The temporary teeth drop out in about the same order as they 
appear. 

Scarcely a year elapses after calcification of the milk-teeth is com- 
plete before absorption begins. 

1 "Gray's Anatomy," eighth edition, p. 753. 
(380) 



Dentition. 381 

Normally absorption begins at the apex of the root and advances 
toward the crown. Shortly after the root has disappeared, the crown 
is removed either by the advancing permanent tooth or by an accidental 
rupture of the attachment between the neck of the tooth and the mucous 
membrane of the gum. 

DEVELOPMENT AND ERUPTION OF THE PERMANENT TEETH. 

The germs of the first permanent molars appear during the fourth 
month of embryonic life. At about the same time may be noticed the 
first steps in the formation of the twenty anterior teeth of the second 
set. The germs of the second permanent molars do not show them- 
selves until the third month after birth, and those of the third molars 
(wisdom teeth) not before the third year. 

The epithelial cords of the twenty anterior teeth spring from the 
epithelial cords. of the corresponding temporary teeth. The cords for 
the twelve permanent molars arise either from the epithelium of the 
mouth, or from successive extensions backward of the epithelial cords of 
the posterior milk-teeth. 

The development of the permanent teeth is similar to that of the 
deciduous teeth. 

Calcification of the permanent teeth begins in the first molars 
about the sixth month of foetal life. 

"First year after birth, central and lateral incisors begin calcifi- 
cation. At four years of age, cuspids, bicuspids, and second molars 
begin calcification. At eight years of age, the third molars begin cal- 
cification." 1 

To accommodate the developing molars, the jaw increases in length 
by the addition of bony material at the posterior border. As the per- 
manent teeth erupt, the sockets and roots of the temporary teeth dis- 
appear by absorption, and new alveoli are built for the second set. 

Ordinarily, the permanent teeth erupt at the following periods, 
the teeth of the lower jaw preceding' those of the upper; — 

Sixth year, first molars. 

Seventh year, central incisors. 

Eighth year, lateral incisors. 

Tenth year, first bicuspids. 

Eleventh year, second bicuspids. 

Twelfth to thirteenth year, canines. 

Twelfth to fifteenth year, second molars. 

Seventh to twenty-first year, wisdom-teeth. 

PRECOCIOUS DENTITION. 

It is not uncommon for dentition to begin prior to the sixth or 
seventh month. Some children are even born with teeth. Many inter- 
esting examples of this singular anomaly have been placed on record. 

"Gray's Anatomy," eighth edition, p. 753. 



382 Dentition. 

The younger Pliny states that the Roman Consul Manius Curius had 
a full set of teeth at birth, on account of which he was named Dentatus. 
I have known of two infants each of whom was born with a tooth 
through the gums. 

In some congenital cases, teeth are less dense than normal teeth, 
have no root, become loose and drop out during the first few months 
of life, and are replaced by the deciduous teeth proper. In other cases 
these congenital teeth have been known to remain until dispelled by the 
permanent teeth, and were therefore undoubtedly genuine milk-teeth. 

Precocious dentition is usually associated with premature ossifica- 
tion of the bones, particularly those of the head. As a consequence 
there is early closure of the fontanels and sutures, which may interfere 
with the normal development of the brain. 

After the premature eruption of one or more teeth, dentition may 
cease from four to twelve months, or even longer, as a result of mal- 
assimilation from some cause. 

Premature dentition is believed by some observers to be evidence 
of tubercular, scrofulous, or syphilitic diathesis. It is, however, some- 
times observed in children in whom no inherited taint can be discov- 
ered. 

RETARDED DENTITION. 

It is very common for the beginning of dentition to be deferred 
for several months after the normal period. In some rare cases teeth- 
ing does not commence until the second year or later. 

Delayed dentition is an indication of a late general development, 
and in the vast majority of cases, the result of rachitis. As a rule, in 
cases of protracted teething the anterior fontanel closes later than the 
seventeenth month, the normal period, and ossification of the bones is 
also delayed. Teeth that are cut late are frequently marked by imper- 
fections of the enamel, lack of density, and decay very early. 

ABSENCE OF TEETH. 

Deficiency in the number of teeth is of more frequent occurrence 
in the permanent than in the temporary set. A milk-tooth may fail 
to appear because of the destruction of its germ by traumatism or dis- 
ease. In the permanent set the upper lateral incisors are most fre- 
quently found missing. Cases are reported where a missing tooth has 
been found lying horizontally in the jaw. The total absence of teeth 
is an exceedingly rare anomaly. There are but few cases said to be on 
record. 

IRREGULARITIES IN THE ORDER OF ERUPTION. 

It is not uncommon for the normal order of eruption to be vio- 
lated. The upper incisors often erupt first, and when such is the case, 
their appearance is usually delayed. The lateral are sometimes cut 
before the central incisors. In rare instances the molars or canines 



Dentition. 383 

precede the incisors, a posterior molar erupts before a canine, or a 
canine protrudes prior to an anterior molar. 

MALPOSITION OF THE TEETH. 

Malposition of individual teeth is of much less common occurrence 
in the deciduous than in the permanent set, and when found is usually 
limited to a slight torsion, or overlapping of the upper or lower 
incisors. The permanent teeth most frequently malposed are the infe- 
rior incisors and canines ; next, the superior incisors ; after these, the 
third molars. 

All sorts of irregular arrangements are seen. The involved teeth 
may be twisted on their axes, overlay one another, or be displaced 
within or without the dental arch. 

Displacement of the teeth occurs when the jaw is too small for 
their proper accommodation. The blending of types by the inter- 
marriage of different races is a well-recognized source of a small jaw 
and large and displaced teeth. 

Persistent thumb-sucking is said to cause a forward direction of 
the upper anterior teeth and a backward inclination of the lower front 
teeth, with more or less deformity of the jaw. 

MALFORMATIONS OF THE TEETH. 

There are numerous departures from what may be regarded as 
the typical form of a tooth. Large teeth with very small roots, an 
increased number of cusps or fangs, outgrowth from the crown or 
fang, twisting, bending, division, or coalescence of the roots, are among 
the variations in shape. 

The surface of a tooth is often marked by transverse or vertical 
ridges and furrows or pittings, the enamel being apparently perfect. 
These ridges and furrows are analogous to the ridges and grooves seen 
on the nails, both the result of interrupted nutrition. 

The enamel of a tooth may present a few excavated spots or a gen- 
eral honeycombed appearance, due to a disorganization of this struc- 
ture. Sometimes the crown of a tooth is entirely devoid of enamel. 

Pigmented spots, and spots having the appearance and consistency 
of chalk, are not uncommonly observed. 

A large proportion of artificially-fed children have faulty per- 
manent teeth later in life. 

There is sometimes an absence of enamel at the middle of the 
biting edges of the upper central incisors. The exposed dentine is 
soft and but partly calcified, and is soon worn away, leaving a cres- 
centic notch in the edge of each tooth. Notched milk-teeth are of no 
special diagnostic import. But when the permanent upper central 
incisors are notched, they are almost invariably an indication of con- 
genital syphilis. 

Mr. J. Hutchinson was the first to call attention to this condition 
of the teeth in inherited syphilis. They are known as "Mr. J. Hutchin- 



384 Dentition. 

son's teeth." This peculiarity in the upper central incisors was at 
one time thought to be caused by stomatitis ; but at present it is believed 
to be the result of an arrest of development in the central or first- 
formed portion of the teeth. 

In subjects of congenital syphilis, both the temporary and the 
permanent teeth may be crescentic. A number of such cases have 
come under my observation. 

SYMPTOMATOLOGY AND ALLEGED DISORDERS OF DENTITION. 

Dentition is a purely physiological process, and, like other phys- 
iological processes, is subject to irregularities from local and consti- 
tutional disorders. It is affirmed, however, that its etiological potency 
is questionable. 

It is true, functional derangements and organic disease are more 
common, and the mortality greater, between the ages of six months and 
two years than at any other period of childhood; but hereditary, die- 
tetic, hygienic, and educational influences are said to furnish causes 
more rational and demonstrable than the presumed irritation of a 
hidden tooth germ. 

There never has been any unanimity of opinion on the subject 
of how teething produces the numerous disorders attributed to it. 

It is said that dentition is more severe in the winter than in the 
summer, and vice versa; that it is more so in the large cities than in 
the country, and its consequences are more serious in badly-nourished 
children and among the poor; that diseases during dentition are ren- 
dered more dangerous by this process; that teeth erupt with more 
difficulty during the course of any severe malady; that the cutting of 
the incisors, on account of their sharp edges, is more painful than the 
extrusion of molars ; that the eruption of the molars causes the most 
pain because of their broad crowns ; that the eye-teeth, owing to their 
long fangs, are liable to give rise to cerebral disturbances; that the 
protrusion of the stomach-teeth is likely to be attended with vomiting 
and diarrhea or cough ; that it is the evolution of the molars that causes 
the most cerebral and intestinal troubles. Then, again, the forward 
pressure of the advancing tooth-crown on the superimposed gum, the 
backward pressure of all the teeth together, are thought, by their 
respective advocates, to account for the many complicating ailments of 
dentition. 

In the estimation of many writers the semeiology of dentition 
embraces drooling, rubbing the one jaw or the other, biting the 
fingers or any hard substance that can be carried to the mouth, fever, 
restlessness, peevishness, fretfulness, disturbed sleep, flushing of the 
cheeks, itching of the nose, dilated pupils, conjunctivitis-otalgia, pain 
and inflammation of the gums, aphtha, thrush, anorexia, vomiting, diar- 
rhea, bronchitis, convulsions, local spasms, and paralysis, and cutaneous 
eruptions. Drooling is said to be the first indication of approaching 
dentition, and it is thought to be the result of a stimulation of the 



Dentition. 385 

salivary glands by an irritation transmitted through the chorda-tyrnpani 
from the gums. It is believed that drooling keeps the gums soft, 
relieves the congested capillaries of the gums and mouth, and "drives 
the blood from the brain, and moderates its irritative condition." 

Slavering is observed to commence in all healthy and normally- 
developed infants between the third and fifth months, and generally 
ceases before the eighteenth month. In sickly and backward children, 
it usually begins later, and may continue for several years. 

While the infant is fed at the breast, there is no requirement for 
either teeth or saliva ; still the development of both the teeth and the 
salivary glands must of necessity be well advanced toward- completion 
before the period of weaning. Hence, instead of regarding this copious 
flow of saliva as a manifestation of a morbid action of the salivary 
glands dependent upon dental irritation, it would be more reasonable to 
assume that it, like the eruption of the teeth, simply betokens a stage 
of developmental activity in which there is a preparation of the digest- 
ive organs for the reception and utilization of the aliment that is to 
succeed the maternal milk. 

The rubbing of one jaw on the other and biting on the fingers or 
any substance that can be carried to the mouth, are supposed to be 
indicative of a feeling of uneasiness or itching in the gums induced 
by the upward pressure of the teeth ; and some smooth and hard mate- 
rial is recommended for the child to bite on, with the view of allaying 
the pruritus and hastening the absorption of the superimposed gum. 

Jacobi says: "Is it astonishing that an infant will, during denti- 
tion, take everything to its lips and into its mouth, after it has done so 
all its life ? The principal impression an infant obtains depends on 
its relation to food and drinks. Eating is the only real propensity an 
infant has, and the mouth is known by experience to be the great recep- 
tacle destined for the reception of everything around ; not to speak of 
the lips being used as a means of touching, grasping, and learning the 
qualities of things." 

The grinding of the teeth in children who have completed their 
first dentition is evidently at times due to some derangements of the 
economy. The biting motion of the jaw in infants before and during 
dentition may likewise be occasionally excited by some irritation, but 
it is not necessarily seated in, or reflected from, the gums. It should 
be remembered that muscular action is essential to muscular develop- 
ment ; that a healthy child is in almost constant motion while awake ; 
and that the masticatory movements may be, and probably are, but a 
part of the general gymnastics in which the child indulges. An infant 
can not walk, neither can it masticate food, yet it exercises both the 
muscles of locomotion and those of mastication, developing and educat- 
ing them for their respective functions, when, at a later period of 
existence, these shall become necessary. 

Fever, restlessness, peevishness, fretfulness, and disturbed sleep 
are the commonest manifestations of infantile derangements. Fre- 

25 



386 Dentition. 

quently they are coincident with eruption of a tooth or a group of teeth. 
When such is the case, a superficial examination may lead the physi- 
cian to conclude that a relationship exists between them, whereas a 
careful and thorough investigation will generally bring to light some 
associated condition which at another time would be considered quite 
adequate to produce these symptoms. If fever and general irritability 
were symptomatic of dentition, they should be continuous throughout 
its whole duration, or co-incident with the eruption of each group of 
teeth, instead of appearing at uncertain times ; and, furthermore, they 
should be present in at least a mild degree in every child. 

* Slight disorders, presenting a few indefinite symptoms, occur at 
all ages, and the physician is now and then at a loss to satisfactorily 
account for them. Peripheral impressibility is very pronounced in 
the infant, particularly in one whose power of resistance is lessened 
by some constitutional vice ; and any slight irritation, as from indigest- 
ible food or parasites in the alimentary canal, constipation, disarranged 
clothing, a misplaced pin, or a soiled napkin, may give rise to a greater 
or less degree of fever and general uneasiness. 

Very often trifling disorders that are viewed as evidence of diffi- 
cult dentition are directly or indirectly dependent upon rachitis. This 
is one of the most common of children's diseases, and frequently a mild 
form of the affection passes unrecognized because its symptoms have 
received a wrong interpretation. The local and general disturbances, 
in the estimation of the parents, and not infrequently in that of the 
physician, too, merely mark the dreaded teething epoch, the attendant 
perils of which every infant is destined to encounter. The tardy den- 
tition and lateness in walking are regarded as nothing but harmless 
freaks of nature, and instances are cited where the same peculiarities 
have been noticed in other members of the family. When rachitis is 
recognized — and it should be before any deformities of the bones are 
visible — and an appropriate line of treatment adopted, recovery gen- 
erally follows ; the teeth are cut rapidly, and, owing to the extra atten- 
tion bestowed on the child, few, if any, of the ordinary derangements 
of infancy occur. 

Vasomotor disturbances, as the transient flushing of the cheeks, 
or sudden pallor of the countenance, are often noticed during the time, 
and, it is said, are a consequence of dentition. But it should be remem- 
bered that there are many conditions in which these symptoms are pres- 
ent, and they must receive careful consideration before making a diag- 
nosis of difficult dentition. It will then seldom be necessary to fall 
back on teething. 

Conjunctivitis is said, now and then, to occur on the side on which 
the teeth are protruding. 

Otalgia, as is indicated by crying and the carrying of the hand to 
the side of the head, has been declared one of the reflex disturbances 
of dentition. In congestion or inflammation of the middle or external 
ear, meningitis, or cerebral hyperemia, the child carries its hand to 



Dentition. 387 

the neighborhood of the ear, and gives evidences of suffering. Most of 
the earache in children is dependent upon acute ostitis; and many an 
ostitis is neglected until the organ of hearing is irreparably damaged, 
because "the doctor said the ear would stop running when the child 
cut all its teeth." "The doctor" had evidently forgotten that the same 
predisposing and exciting causes could be operative before the eruption 
of the last of the twenty milk-teeth as afterwards. 

Redness, swelling, and tenderness of the gums during the time 
of dentition are generally held to be symptomatic of some difficulty in 
the eruption of the teeth. 

The gums of a healthy child are of a pale pink hue. As a tooth 
approaches the surface the gum in that locality becomes more promi- 
nent, grows paler in color, until it is almost white, and is anything but 
sensitive. Over the summit of a tooth just before it reaches the sur- 
face, a depression is often observed, due to the disappearance of the epi- 
thelial and subepithelial layers, by a necrotic process. Sometimes the 
gum over the crown of an erupting tooth becomes inflamed and tumid, 
and an incision may give exit to a drop or two of thick, black blood. 
The gum s round the top of a tooth that is partly through the gum is 
oftentimes inflamed. This condition will be seen where repeated 
attempts have been made at "rubbing the tooth through" with a thim- 
ble, finger-nail, or other hard substance. Ulceration of the gum over 
a tooth now and then occurs from impingement of a sharp corner of 
a corresponding tooth that has erupted in the opposite jaw. 

It is said that it is doubtful if dentition be ever the sole cause, 
or indeed a cause at all, of gingivitis. 

When stomatitis is present, some cause other than dentition should 
be sought. The vast majority of cases of stomatitis occur in bottle-fed 
children. It is generally associated with some derangement of the 
organism, particularly the digestive tract. The child's diet or hygiene 
is usually at fault. The use of foul nursing-nipples, a dirty teething- 
ring, and filthy sugar-teats, thumb- and tongue-sucking, and irritants 
taken into the mouth, as hot fluids, principally tea and coffee, drugs, 
or substances the child may pick up while wandering around on the 
floor, may give rise to stomatitis. 

Diarrhea in teething children has by some writers been attributed 
to the swallowing of large quantities of saliva, the salts contained in 
it being supposed to act as a mild aperient. By others, the reputed den- 
tal diarrhea is thought to be of a neurotic character — an irritation being 
transmitted through the sympathetic nerves to the vagus, influencing 
the glandular secretion of the digestive tube or producing a hyper- 
peristalsis of the intestines. 

Yogel says, "A mild diarrhea, five or six evacuations in the twenty- 
four hours, is very beneficial to teething children, for cerebral affec- 
tions are thereby most surely prevented." J. Doming, M. D., says: 
"Many children are sacrificed annually through a belief in such an 
erroneous doctrine. Diarrhea may occur at the time a tooth is pro- 



888 Dentition. 

trading, or at successive periods of dental evolution, but never in con- 
sequence thereof. Children who are fed exclusively at the breast at 
proper intervals, and whose hygiene receives careful attention, seldom 
suffer with a diarrhea before the period of weaning. Then, again, 
diarrhea is strikingly more prevalent in one season than in another, 
notwithstanding the eruption of teeth at all periods. These two facts 
rather militate against the theoretical existence of diarrhea from den- 
tal irritation." 

The causes of intestinal derangements are improper feeding, bad 
hygiene, and changes produced in the atmosphere, especially in a city, 
hf a high degree of solar heat. The most significant of these causes of 
diarrhea, it must be borne in mind, is improper feeding. Most babies 
at the breast are nursed too often. Bottle-fed infants, in addition to 
being fed too frequently, labor under the disadvantage of not having 
provided for them a suitable substitute for their natural food. 

Too commonly undue importance is attached to the appearance of 
the first tooth. Its presence is hailed as the beginning of a new era in 
the child's existence, and no opportunity is lost in putting the anxiously- 
watched-for organ to a legitimate use. 

Bronchitis is thought to be due to the saturation of the covering 
of the chest with saliva that flows from the child's mouth — a plausible 
view. It is also said to be due to a nervous irritation reflected from 
the gums. 

Because an attack of bronchitis will now and then subside on the 
eruption of a tooth, it does not follow that the cutting of the tooth is 
the cause of the bronchial inflammation; for a mild attack of bron- 
chitis will get well spontaneously in a child free from any predisposi- 
tion, whether a tooth be coming through or not. After a child has 
begun to creep or walk, it is more exposed to atmospheric changes than 
earlier in life; hence the greater frequency of attacks of bronchial 
catarrh during the second year. Rachitic and scrofulous children are 
subject to recurring attacks of bronchitis ; and the great prevalence of 
rachitis should not be overlooked. 

Convulsions varying in form from slight twitchings of particular 
groups of muscles to a general eclamptic attack, are said to have an 
origin in dentition. Frequently a child will sleep with the eyes half 
open and the eyeballs rolled upward, presenting a most appalling spec- 
tacle to the inexperienced mother. Or a smile will occasionally flit 
over the infant's countenance, caused by the contraction of the facial 
muscles — a pleasing sight to the sentimental mother, whose creative 
imagination conjures up a vision of angels whispering to her sleeping 
babe. 

Now and then a general convulsion will occur, perhaps with the 
eruption of a tooth, or at successive periods of dental protrusions. 

But it must be remembered that during the dentition period or 
epoch the whole organism is in a state of active development; that 
the nervous system has not acquired the stability or equilibrium of 



Dentition. 389 

the youth or adult, and is therefore extremely susceptible to external 
impressions, as is evidenced in the marked manifestations of disturbed 
function that are produced by what in the more mature individual 
would be considered trifling affairs. The convulsions are much more 
extensive in infancy and childhood than later in life. 

In the majority of cases, convulsions are traceable to some irri- 
tation in the alimentary canal. Rachitic children are peculiarly liable 
to convulsions. In some cases, the most painstaking examination fails 
to reveal the cause of the convulsion. 

Cutaneous eruption — notably, eczema, lichen, uticaria, and impet- 
igo — are very common between the sixth and twenty-fourth months, 
and, like diarrhea and convulsions, may appear contemporaneously with 
the cutting of a tooth. 

The delicate and sensitive nature of the child's skin renders it 
susceptible to disorders from slight irritation. Inherited or acquired 
predisposition, derangement of the digestive organs, usually from some 
fault in the diet, some disturbance of the nervous system (not always 
to be accounted for in an adult), lack of cleanliness, immoderate bath- 
ing, the use of strongly alkaline soaps or impure toilet powder, rough 
handling in washing, drying, or dressing the child, irritation from the 
clothing in either quality or arrangement, but not dentition, may give 
rise to cutaneous eruptions. 



CHAPTER XXIV. 
PUBERTY: ITS PATHOLOGY AND HYGIEXE. 

Puberty has been denned as the period of life within which repro- 
ductive capacity becomes established. The term "puberty" will be 
used as signifying merely the epoch intervening between childhood and 
adult age or manhood. Under ordinary circumstances, this period is 
marked by the evolution of the organs of generation, together with 
those protean physiological changes and new etiological relations that 
are connected therewith. So important and complex are the latter 
that of all the successive stages of growth, maturity, and decay into 
which the brief span of human existence is biologically divisible, there 
is perhaps no one epoch the pathological aspects of which are of such 
frequent interest to the medical practitioner as that which forms the 
subject under consideration. 

In infancy and childhood the vital powers are occupied exclusively 
with the nutrition and growth of organ's essential to the existence of the 
individual. During puberty, on the other hand, in addition to this, 
as a rule there now occurs the still more remarkable evolution, struc- 
tural and functional, which controls the perpetuation of our species. 
The physiological actions which are necessary for their object are, as 
was well observed by Dr. Roget, "great and commensurate with the 
magnitude and importance of the design," and they give rise to that 
rapid and varied succession of changes, mental as well as physical, 
which are essential for the perfected development of that marvelous 
trophy of creative power, — "the living microcosm of man's body." 

!Nor are these developmental changes purely physiological, but, on 
the contrary, inasmuch as "the seeds of death are inseparably inter- 
mixed with the germ of life," they are closely connected with, or pro- 
ductive of, numerous special pathological proclivities or tendencies to 
disease, which will be separately considered in the succeeding pages. 

CIRCUMSTANCES AFFECTING THE EVOLUTION OF PUBERTY. 

The age when the vital changes usually included in the term "pu- 
berty" may take place does not admit of any rigid limitation, as their 
occurrence is necessarily so affected by inherited predisposition or fam- 
ily temperament, constitution, or idiosyncrasy, and the incidents and 
circumstances of life, in each individual, as well as by the agency of dis- 
ease, and above all by the potent influence of climate, as to preclude the 
possibility of more than a mere approximation to any general rule in 
reference to the normal date of the commencement of this epoch. 

(390) 



Puberty: Its Pathology and Hygiene. 391 

PERIOD OF ESTABLISHMENT OF PUBERTY IN FEMALES. 

The advent of female adolescence is datable from the first appear- 
ance of the catamenia, which, ceteris paribus, occurs earliest in warm 
climates, sanguine temperaments, and highly civilized and luxurious 
states of society, and is retarded by the opposite conditions. In the 
southern climate in this country it is very common for the catamenia 
to appear much earlier than it does in the northern portion of the 
country. The writer has observed its appearance at ten and eleven 
and twelve years of age. The writer had a case of an infant who 
menstruated in four weeks after birth for four days, natural flow to all 
appearances. The parents of the child did not wish the case to be 
known, and moved to the country, and the case could not be kept 
track of. 

More frequently, however, in cold or temperate climates such as 
ours, the evolution of menstruation is retarded beyond the usual period. 
In several instances I have known of cases who were sixteen and seven- 
teen years of age before the first appearance of the catamenia. Dr. 
Gwinn, in his "Dictionary of Medicine," shows the result of an inves- 
tigation by Dr. Madden, in which he says : "This investigation extended 
over a considerable period and a large field of inquiry, having been 
commenced during my connection with the Rotunda Lying-in Hos- 
pital, and subsequently being continued in the gynaecological wards of 
the institution to which I have been attached for the last twelve years. 
The great majority of statements of those whose menstrual history was 
investigated, proved so indefinite or unreliable that in only an infinitesi- 
mal proportion of them — namely, in four hundred and ninety-seven 
instances — was I able to obtain any accurate data on this point. In 
these latter cases the ages at which menstruation first occurred were 
as follows: — 

Under 12 years of age 4 menstruated for the first time. 

At 12 years of age 17 menstruated for the first time. 

At 13 years of age 50 menstruated for the first time. 

At 14 years of age 94 menstruated for the first time. 

At 15 years of age 138 menstruated for the first time. 

At 16 years of age 105 menstruated for the first time. 

At 17 years of age 65 menstruated for the first time. 

At 18 years of age 10 menstruated for the first time. 

Over 18 years of age 14 menstruated for the first time. 

"From the foregoing table it appears that of four hundred and 
ninety-seven cases where the date of the first catamenial period was 
ascertained, menstruation occurred between the fifteenth and seven- 
teenth years in three hundred and thirty-seven instances, and that in 
this triennial period its first manifestation most commonly took place at 
the sixteenth year, which may therefore be regarded as the average 
normal date of the commencement of female puberty." 



392 Puberty: Its Pathology and Hygiene. 

EVOLUTION OF FEMALE PUBERTY. 

The transition from girlhood to puberty, the normal date of which 
has been referred to, is, notwithstanding the far greater complexity of 
the physiological changes involved, much more direct and sudden than 
is the case with the corresponding period in the opposite sex. In the 
primary stages of life the functional differences between the sexes are 
comparatively slightly marked; but on the occurrence of puberty in 
the female, these become sharply accentuated. They are noted by the 
sudden development of the reproductive or sexual organization, includ- 
ing the accessory parts, such as the mammas and external genitals, as 
well as the essential organs of generation, and more especially the 
enlargement of the ovaries, the maturation of their Graafian follicles and 
contained ova, and, in fine, the evolution of the entire utero-ovarian 
system, the predominant influence of which on the general economy is 
tersely summed up in the old aphorism, "Proptes uterum est mulier." 
From this moment the girl passes at once from childhood to full pro- 
creative maturity, as evinced by the establishment of menstruation. 
This function, which results from the processes of ovulation and uterine 
denudation, leads to that periodic sanguineous discharge by the regular 
monthly recurrence of which, during the ensuing thirty years or so of 
life, the term of woman's distinctive sexual reproductive vitality is 
measurable. 

PERIOD OF PUBERTY IN THE MALE. 

The commencement of this epoch in man is less definite in its 
characteristics and in the age of its occurrence, than is the case with 
the opposite sex. a In Great Britain," and I believe a similar law gen- 
erally prevails in this country, "a boy is not legally considered as 
arrived at puberty until the age of fourteen, when supposed sexual 
capacity and legal responsibility for the crime of rape commences. " 
By the old Roman, however, another and a better standard of adoles- 
cence was provided, this term being considered synonymous with the 
period at which liability to military service began, namely, at the 
age of fifteen, the ordinary date at which the physiological change from 
boyhood to manhood, to puberty, occurs in all temperate climates. 
The approach of this epoch is now denoted by a characteristic modula- 
tion of the voice, which becomes altered from "thin, childish treble to 
the deep, manly bass," caused by the development of the larynx and 
vocal cords, the enlargement of the pomum Adami, and the elongation 
of the thyroid cartilage and the thyroarytenoid muscles. About the 
same time is also noticeable the first appearance of that downy growth 
on the face, so fondly watched and cultivated by its proud possessor as 
the badge of emancipation from "the pedagogue's stern rule," and the 
evidence of the advent of the bright springtime of life, when 

"A young man's fancy lightly turns to thoughts of love." (Madden.) 

There now also occurs the growth of hair on the pubes, etc., the 



Puberty: Its Pathology and Hygiene. 393 

commencement of the structural and functional development of the 
testes and other parts of the genital organs, and their instincts. The 
successive changes, however, proceed so gradually that their full com- 
pletion is not reached until some years have elapsed, and is said often 
to be delayed until long after the legal term of manhood has been 
attained. 

PREMATURE PUBERTY IX MALES. 

Although, as already observed, the vital changes connected with the 
transition from childhood to adolescence are, under ordinary circum- 
stances, seldom accomplished before the sixteenth year, and are fre- 
quently delayed until a much later period of life, occasionally this 
customary course is departed from, and in these fortunately exceptional 
instances the whole system, physical and mental, or, as more frequently 
is said to happen, particular powers or organs, become prematurely 
developed at an abnormally early age. There are numberless instances 
of mental precocity on record. As Dr. Elliston has observed, a per- 
fectly authentic case has removed all doubts respecting the boy at 
Salamius mentioned by Pliny (Hist. Nat. Lib. VII, C. 17) as being 
four feet high and having reached puberty when only three years old, 
and respecting the man seen by Craterus, the brother of Antigonus 
(cited in Blumenbach's Physiology, fourth edition, p. 535), who, in 
seven years, was an infant, a youth, an adult, a father, an old man, 
and a corpse. 

If the mental faculties be too early developed, with an almost 
absolute certainty of their subsequent failure at a correspondingly 
untimely age, it is not to be wondered at that a like extraordinary pre- 
cocity should in some unfortunate instances exhibit itself in a pre- 
mature evolution of the sexual functions, the unhappy subjects of 
which, instead of growing up with gradually increasing vigor to the 
possession of a healthy manhood, sink into a premature old age, men- 
tally imbecile and physically decrepit, at what should normally have 
been a period of vital maturity. 

DISEASES OF PUBERTY. 

Of the various factors we notice in the etiology of disease, there is 
none more obvious in its effects than the influence of age in the causa- 
tion of the chief maladies to which each period of life is specially sus- 
ceptible, and which seldom occur at other epochs. Thus, as remarked 
by Dr. Elliotson, "we rarely see gout in an infant, nor is it common 
for old persons to have the symptoms of acute hydrocephalus." This 
elective affinity of certain disorders for particular ages, is strikingly 
exemplified during puberty by the special tendencies then manifest in 
both sexes to development of strumous or tuberculous disorders and 
gastro-intestinal complaints, as well as by the various acute inflamma- 
tory and hemorrhagic diseases — pulmonary, cerebral, and hepatic — 
which are then so prevalent ; whilst in females the special pathological 



394 Puberty: Its Pathology and Hygiene. 

proclivities accompanying puberty are, as will be seen later on, still 
more directly connected with the newly-developed functional activity 
of the utero-ovarian system. 

SPECIAL DISORDERS OF FEMALE PUBERTY. 

The chief characteristic of the change from girlhood to puberty, 
which in our climate generally occurs at the fifteenth year of age, or 
thereabouts, consists in the regular establishment of that periodic action 
of menstruation, for the accomplishment of which the conjoint func- 
tional activity of the ovaries, Fallopian tubes, and the uterus, is essen- 
tial. This process commences in ovulation, or the maturation of a 
Graafian follicle, followed by the escape of the contained ovum, and 
its transmission by the Fallopion tube into the uterus, whereupon there 
also occurs a disintegration, or shedding of the endo-uterine lining mem- 
brane, which, the subjacent surface thus unsealed, leads to a hemor- 
rhagic exudation or discharge per vaginam, amounting to six or eight 
ounces, and extending over a period of from three to five days. I have 
known some who menstruate seven days, it being their natural diathesis. 
Immediately before the catamenial epoch, the patient suffers more or 
less from general malaise, languor, and heaviness ; she is indisposed 
to exertion, and complains of pain in the back and loins, and down the 
thighs ; occasionally there is some uneasiness and a sense of constriction 
in the throat and about the thyroid glands. There is a peculiar dark 
shade over the countenance, and especially underneath the eyes; the 
cutaneous perspiration and breath have a faint sickly odor ; the mamma? 
are enlarged and often painful; digestion is sometimes impaired, 
and the appetite fastidious. After these symptoms have been present 
for a day or two, under normal circumstances, the menses appear, and 
the uneasiness subsides. 

In a large number of cases, however, the nervous disturbances con- 
nected with the establishment of menstruation are of a more serious 
nature than in those just referred to, and these will now be considered. 

HYSTERICAL DISORDERS OF PUBERTY. 

The frequent occurrence of hysterical and other cerebro-nervous 
disorders in females about the age of puberty, which we find so often 
in our daily practise, is evidently strictly consequent on the complex 
structural and functional changes then in process in the reproductive 
system, the predominant influence of which is manifest in every vital 
action from the dawn of puberty until the termination of the period 
when utero-gestation is possible. The commencement of this epoch is 
marked by a sudden and complete revolution in the female mental as 
well as physical constitution. At each succeeding ovulation there is 
also a coincident recurrence of constitutional and nervous disturbance 
acting on the general system through the widespread ramifications 
of the vasomotor sympathetic system, so that no woman should allow 



Puberty: Its Pathology and Hygiene. 395 

the approach of her husband at these periods, which I have often been 
told is the case. A woman is "unclean," and should occupy a separate 
room at these monthly epochs. 

When menstruation has become established, and is regular in every 
respect, the accompanying nervous disturbance may be so slight as to 
escape observation. But the earlier catamenial periods, as well as 
every subsequent deviation from normal menstruation, are so fre- 
quently attended with some manifestation of hysteria under the guise 
of nearly every complaint then incidental to female youth, that whether 
the trouble be spinal, cardiac, pulmonary, or indeed any of those obscure 
complaints common to that age, and for which no obvious physical evi- 
dence is apparent, the experienced practitioner may very frequently 
be able to trace the trouble to the sympathetic nervous disturbances 
that are connected with the evolution of puberty. It scarcely need be 
added, however, that Avhilst thus prepared to meet with the protean 
forms of hysteria, simulating and complicating the most common dis- 
eases prevalent during this epoch, the physician should be no less fore- 
warned against the much graver error of ignoring or neglecting the 
obscure evidence of actual physical disease in any patient, however 
hysterical she may be. 

It would be impossible, within the limits of this article, to refer 
in any way to the widely-extended list of authors, of every age and 
country, by whom the hysterical disorders of puberty have been 
described. One of the earliest writers on this subject was Hippoc- 
rates, who observes, "Nubile virgins, particularly about the menstrual 
period, as being affected with epileptic paroxysms, apoplexies, and 
groundless fears and fancies." He attributes these to a congestion 
about the heart and diaphragm. "When these organs are oppressed, 
rigors and feverishness supervene; the patient raves about the acute 
inflammation, cries out on account of putridity, is terrified and anxious 
on account of her dimness of vision, and from the oppression about 
the heart thinks suffocation is pending. The mind is harassed by 
anxiety and weakness, and becomes diseased. The patients call out in 
great alarm, desire to leap down or throw themselves headlong into 
pits, and order themselves to be strangled, as if it were a thing beyond 
all others to be desired. Specters haunt them, and they earnestlv lone; 
for death as for a pleasure. The disease is easily cured if nothing 
retards the flow of the menses." He adds: "To those young females 
affected by it, I recommend that they marry as quickly as possible ■ for 
if they conceive, they will escape the disease. Spinal and abdominal 
tenderness, tympanitis, aphonia, syncope, etc., were observed then just 
as they are at the present time, in such cases." 

THE VOICE IN HYSTERIA. 

As a general indication of hysteria the changed character of the 
patient's voice in such cases must be mentioned. This alteration con- 
sists in a loss of that peculiar softness and melody which distin<niish 



396 Puberty: Its Pathology and Hygiene. 

the female from the male voice. In hysteria the patient's intonation 
either becomes more rough and masculine than normal, or else becomes 
more shrill and piercing or metallic than usual, as well as more rapid 
in the sequence of its modulations. The hysteric voice is not easily 
described; but once recognized, it is, I believe, an unmistakable evi- 
dence of nervous functional disturbance consequent on some derange- 
ment of the utero-ovarian function. 

The earlier nervous symptoms that frequently occur at puberty 
may for a time be unrecognized; but as the local disease progresses, 
these come into such prominence as in many cases to obscure all the 
evidence of their physical exciting cause; the most important of these 
hysterical manifestations are increased nervous susceptibility, or gen- 
eral hyperesthesia and diminution of inhibitory nerve-force, together 
with perverted moral or mental excitability, and in some cases actual 
delusions. This condition is more frequently coexistent with amenor- 
rhoea, or dysmenorrhea, resulting from uterine disease or displacement, 
than any pathological increase in its function. 

HYSTERICAL INSANITY. 

The connection between mental disease and menstrual disorders, 
more especially amenorrhoea, has been frequently observed by gynaecol- 
ogists. Thus, in a case related by Pinel, a girl suffering from insanity 
was placed under his care shortly before the ordinary age of puberty, 
which passed over without the occurrence of the usual changes con- 
nected with this period. After a considerable lapse of years, however, 
one day on rising from her bed, she ran and embraced her mother, 
exclaiming, "I am well." The catamenia had just flowed for the first 
time, and her reason was restored, both the mental and reproductive 
system thenceforth permanently resuming their normal functional 
condition. 

HYSTERICAL EPILEPSY. 

This disease is said to be invariably accompanied with some 
derangement, and more generally suppression, of the menstrual func- 
tion. 

HYSTERICAL TRANCE. 

Hysterical evidences of utero-ovarian disorder connected with the 
evolution of puberty, may also manifest themselves by diminished 
nervous activity and general or local anaesthesia; and as well by the 
opposite condition. To illustrate, as stated by Dr. Badden, a as an 
instance of so-called hysteric trance : A young lady, recently arrived at 
puberty, of an hysterical temperament, but otherwise apparently in 
perfect health, went into her room after luncheon to make some change 
of dress. A few minutes afterward she was found lying on her bed 
in a profound sleep, from which she could not be awakened. When 
I first saw her, twenty-four hours later, she was then still sleeping tran- 
quilly, the decubitus being dorsal, respiration scarcely perceptible, pulse 
seventy and extremely small ; her face was pallid, lips motionless, and 



Puberty: Its Pathology and Hygiene. 397 

the extremities very cold. At this moment so deathlike was her aspect 
that a casual observer might have doubted the possibility of the vital 
spark still lingering in that apparently inanimate frame, on which no 
external stimulus seemed to produce any sensorial impression, with the 
exception, however, that the pupils responded to light. Sinapisms were 
applied over the heart and to the legs, where they were left on until 
vesication was occasioned, without causing any evidence of pain. Far- 
adization was also resorted to without effect. In this state she 
remained from the evening of the 31st of December until the after- 
noon of the 3d of January, when the pulse became completely imper- 
ceptible, the surface of the body was icy cold, the respiratory move- 
ments apparently ceased, and her condition was to all outward appear- 
ance undistinguishable from death. Under the influence of repeated 
hypodermic injections of sulphuric ether and other remedies, however, 
she rallied somewhat, and her pulse and temperature again improved. 
But she still slept on until the morning of the 9th, when she suddenly 
woke up, and, to the great astonishment of those about her, called for 
her clothes, which had been removed from their ordinary place, and 
wanted to come down to breakfast, without the least consciousness of 
what had occurred. Her recovery, I may add, was rapid and complete. 

"In the second instance of the same kind that I have seen, the 
patient, after a lethargic sleep of twenty-seven days, recovered con- 
sciousness for a few hours, and then relapsed into her former comatose 
condition, in which she died." 

I have referred to the foregoing cases, occurring in one physician's 
experience, as disproving the general opinion that hysterical lethargy, 
or trance, is so rarely met with, and is then of such trivial pathological 
importance as to be of little if any practical interest. On the con- 
trary, from my own experience I can vouch that these conditions are 
of far more frequent occurrence than is generally supposed to be the 
case, as well as for the fact that all the ordinary external signs of appar- 
ent death may occasionally be tjius counterfeited with wonderful 
similitude. I would, therefore, take this opportunity of urging the 
necessity of bearing this in view, so as to avoid what I fear is the not 
infrequent possibility of living interment in some cases of too hurried 
burial under such circumstances, — a calamity the horrors of which, I 
may here repeat, no effort of imagination can exaggerate, and for the 
prevention of which no pains can be excessive and no precautions 
superfluous. 

HYSTERICAL PARALYSIS. 

In many instances the nervous symptoms of utero-ovarian func- 
tional disturbance at the period of puberty may also be manifested in 
the simulation of every form of paralysis, from the most trivial local 
loss of power to complete paraphlegia. 



398 Puberty: Its Pathology and Hygiene. 

MENSTRUAL DISORDERS OF PUBERTY. 

The normal course of the evolution of puberty is especially liable 
to derangements arising from the various morbid conditions by which 
the due performance of the function of menstruation may be inter- 
fered with. This disturbance is most frequently occasioned by 
amenorrhea, or the total absence or diminution of the catamenial dis- 
charge; secondly, by dysmenorrhea, or the difficult and painful accom- 
plishment of this function; and thirdly, and less commonly, by monor- 
rhagia, or abnormal activity in the utero-ovarian changes connected 
with ovulation, and consequent excess in the resulting menstrual dis- 
charge. The effects of these disorders are more marked during puberty 
than perhaps at any subsequent epoch; but inasmuch as their occur- 
rence is by no means restricted to this period, it would be beyond the 
scope of the present article to attempt any discussion of their general 
pathology and treatment. 

With regard to the first named of these disorders, viz., amenor- 
rhea, it may, however, be here observed that very undue importance 
is commonly ascribed to the non-appearance of menstruation at the 
usual age, or to its subsequent interruption or diminution, as the sup- 
posed general cause of nearly all the ills to which all female flesh, about 
the period of puberty, is heir. In the great majority of the cases of 
amenorrhea, for which at this epoch we are so frequently consulted by 
anxious mothers, the functional irregularity is merely symptomatic of 
systemic morbid conditions, to the rational treatment of which, by 
appropriate constitutional remedies, rather than to any futile if not 
injurious utero-ovarian or local stimulation, the efforts of the physi- 
cian should in such cases be directed. 

Dysmenorrhea is hardly less frequently associated than amenor- 
rhea with the special hysterical and other constitutional disorders 
incidental to puberty. Under these circumstances, difficult menstrua- 
tion, although occasionally resulting from uterine flexions or displace- 
ments, or from stenosic or other obstructive causes, as well as from local 
inflammatory conditions, is far more commonly merely a complica- 
tion of coexisting general nervous disorders or constitutional hyper- 
esthesia, on the cure of which the dysmenorrhea! trouble will at once 
subside. 

In this connection I may add a note of warning against the popular 
custom, so prevalent among all classes, of treating the dysmenorrhea 
of puberty by wine or brandy or whisky. From long experience I am 
convinced that intemperance in women may very frequently be traced 
back to the first painful menstrual period, when alcoholic stimulants 
are often forced on the young sufferer. The pain of dysmenorrhea 
being thus relieved, the girl at the next similar epoch naturally and 
no longer reluctantly seeks the same solace, until in this way the vic- 
tim of dysmenorrheal alcoholism may gradually become an habitual 
and perhaps an incurable drunkard. Instead of giving spirits of any 



Puberty: Its Pathology and Hygiene. 399 

kind, give a cup of hot ginger tea, and place a hot-water bag over the 
seat of pain and a hot-water bottle at her feet, and they will afford 
immediate relief. 

Chlorosis — or chloronsemia, as green sickness is more properly 
termed, which we have already alluded to in diseases of women, to 
which we refer at greater length in this article, as it is one of the spe- 
cial ailments of puberty — is the most frequent of all the morbid condi- 
tions specially incidental to this time of life. Chlorosis, or green sick- 
ness, may be regarded as a specific form of anaemia; the ganglionic 
nervous system, as a rule, is connected with either amenorrhoea or 
dysmenorrhoea. The history of the disease, its symptoms, and the line 
of treatment by which these may be relieved, all point to the accuracy 
of Kuchenmeister's conclusion, viz., a that the essential cause of the 
chloritic condition is the retention of carbonic acid in the blood." This 
theory is sustained by the fact that the chlorotic are very commonly 
persons of the poorer classes, who, while subsiding on poor food, have 
been deprived of fresh air, sunlight, and exercise, and in whom, from 
the consequent diminution of pulmonary exhalation, aided by the 
lessened menstrual evacuation in such cases, the blood is surcharged 
with carbonic acid as well as poor in red corpuscles. 

Chlorosis is characterized by a universal and decided debility of 
the whole frame, with sometimes a degree of torpor of particular 
organs. The cutaneous surface is of a sallow or slaty pallor, though 
the skin mav be deadlv white without a greenish tinffe. There is a 
general weakness of the muscular system, and weariness and languor 
of body, with listlessness of mind, the patient being indisposed for 
any exertion, easily overcome by fatigue, nervous, low-spirited, and 
frequently a prey to singularities of temper. There is generally 
severe recurrent headache or vertigo, and sometimes an impaired state 
of the memory and of the faculty of attention ; the sleep is disturbed, 
the chlorotic sufferer being either preternaturally wakeful or abnor- 
mally drowsy. The eye, in welhmarked cases, is dull and heavy; 
the lips and tongue are at first exsanguine and pallid, and subse- 
quently present a peculiar slaty hue. The temperature, more espe- 
cially that of the extremities, is depressed. The pulse is small and 
weak, often rapid, and easily fluttered; there is frequently palpita- 
tion, recurring in attacks, or of a more permanent character ; more 
frequently still there is a sense of sinking in the prsecordia, with 
irregular action of the heart, or imperfect syncope. There is usually 
a degree of breathlessness experienced on any exertion, sometimes fits 
of dyspnoea, sometimes a sonorous cough. The appetite is normal ; 
occasionally it is morbidly increased, but more usually anorexia is 
present, and the patient loathes food, or is sick after eating, or much 
troubled with flatulence and gastrodynia. Often there is a desire for 
indigestible substances, particularly chalk, magnesia, or even cinders. 
The writer had one patient who had an uncontrollable desire for eat- 
ing slate-pencils, and carried one in her dress pocket so that it would 



400 Puberty: Its Pathology and Hygiene. 

be convenient for her to taste it when the desire came on her. The 
bowels are costive, often obstinately so, or if not, the stools are dark 
and offensive. The abdomen is not infrequently tumid, swollen, and 
variable in size. The hands and feet swell at night, with oedema of 
the eyelids, if not of the whole face, particularly in the morning. The 
urine is scanty, though clear. 

In addition to the above symptoms, many other of those obscure 
symptoms which in girls are so frequently met with about the time 
of puberty may also be found connected with chlorosis. Of this kind 
is that severe left-side pain, otherwise inexplicable, so often com- 

flained of at that age, as well as those intense nervous headaches, 
reathlessness, and, in fine, that host of hysterical symptoms by which 
all the features of organic and functional disease, whether pulmonary, 
gastric, or cardiac, may be simulated. 

Treatment. — With regard to the treatment of chlorosis, I will 
repeat that our attention should be primarily directed to the rectifica- 
tion of that error of digestion which is a chief cause of the charac- 
teristic aglobulism, and, secondly, to the depuration of the vitiated 
blood by the excretory organs, rather than, as is too often done in such 
cases, to the restoration of the catamenial discharge, the suppression 
of which should be regarded as merely a symptom — albeit a primary 
and most important one — of the constitutional disease. 

In accordance with this view, the rational treatment of chlorosis 
must be approached by means capable of strengthening the general sys- 
tem, and more especially improving the tone of the organs of digestion 
and excretion. For the first purpose, open-air exercise, free exposure 
to sunlight, and suitable food are more essential than any medicine at 
our command. We would, then, recommend regular exercise propor- 
tioned to the ability of the patient; the use of warm or tepid salt- 
water baths every day, succeeded by friction with dry flannel or a soft 
brush; sufficient clothing, and particularly a flannel dress; a nourish- 
ing and digestible diet; the administration of bitter and tonic medi- 
cines in varied forms, — preparations of iron, such as chalybeate waters, 
tincture of muriate iron, or the carbonate of iron, alone or combined 
with myrrh, or sulphate of iron with quinine, or a grain of iodide of 
iron in a bitter infusion, and arsenic. 

The use of chalybeate mineral waters, internally as well as 
externally, is of self-evident service in the chlorotic state, unless the 
patient be of a full habit, in which case purgatives should be used to 
keep the bowels active. 

TUBERCULOSIS AND STRUMOUS DISORDERS OF PUBERTY. 

We have discussed, in the preceding sections, the most important 
of the special disorders directly connected with the organic and func- 
tional evolution of the reproductive system; we must now briefly con- 
sider some other forms of disease to which the period of puberty is 
especially liable, even although their occurrence is not limited to this 



Puberty: Its Pathology and Hygiene. . 401 

age, and their etiology must in some instances be sought in causes 
operating at an antecedent epoch. Of these maladies the most impor- 
tant in this connection are the various forms of strumo-tuberculous 
complaint, which constitute so large a proportion of the disease of 
puberty, which we so often find in our daily work. According to 
statistics, the disease is notably increasing all oyer the country, from 
east to west, from north to south. It is thought that the explanation 
of this fact must be looked for in circumstances preceding the develop- 
ment of puberty, and is mainly referable to the dietetic and hygienic 
mismanagement of childhood, more especially to the frequent employ- 
ment of unsuitable condiments, such as tinned and other artificial 
so-called milk preparations as substitutes for the natural food essen- 
tial for the healthy nutrition of children in early life. 

The acute forms of tuberculosis which are most common during 
youth have been observed by Cohnheim and Klebs, who say that they 
"resemble the infective diseases in their zymotic origin from a spe- 
cific virus, whether generated in the body from caseous matter or intro- 
duced from without. The latter is probably generally the case in 
the tubercular diseases so common among the children of the poorer 
classes, into whose dietary tinned or preserved milk now enters largely ; 
for there can, I think, be no guarantee that the cows furnishing this 
supply are not suffering from perlsucht, or bovine tuberculosis, as 
the disease is very prevalent, and does not materially affect the quan- 
tity of milk." 

Regarding the frequency of tuberculosis, Prof. Bollinger (Wiener 
Medizin Presse, Sept. 16, 1888) maintains that in large cities from 
forty to fifty per cent of all deaths may be attributed to this disease. 
Recent experiments in his laboratory show that milk may prove infec- 
tious, whether taken from cows suffering with local or from those suf- 
fering with general tuberculosis. 

As in other infectious diseases, the quantity of tuberculous material 
introduced into the economy strongly influences the severity of infec- 
tion. "Only a few drops of undiluted milk from a tuberculous cow 
proved sufficient to produce typical miliary tuberculosis in animals; 
but when the quantity underwent any material dilution, its effects 
were negative." This latter observation would suggest the use of milk 
taken from many cows, rather than from one cow. 

Another cause of the increasing frequency of scrofulous and tuber- 
cular disorders is the physical deterioration of our people, arising from 
that widespread intemperance, which is said to be almost as general 
among the cities and large towns as it is among men, and the con- 
sequent toxicological effect of alcoholism on the wretched offspring of 
these drunken parents, who further pay the penalty of their progeni- 
tor's excesses by the development of scrofula and tuberculosis as the 
result of semi-starvation and neglect during the first years of life. 

It would be impossible to consider here so wide a question as the 
relation of scrofula to tuberculosis. Some eminent writers, Dr. Bad- 

26 



402 Puberty: Its Pathology and Hygiene. 

den, Klebs, and others, say that the scrofulous diathesis is the pro- 
lific and primary source of all tuberculous disease, whatever part of 
the body may be thus affected, whether it be the lungs, the meninges 
or substances of the brain or spinal cord, the mesenteric glands, the 
cancellous structure or articulating surfaces of the bones, or the 
external glandular system. 

One of the most frequent forms of pulmonary tubercular disease, 
as the old writers well termed it, is the "acute or galloping consump- 
tion." In some instances we have seen miliary tuberculization of the 
lungs pass through all its stages, from its first recognition until the 
patient's death, within a few weeks, or in a month's time. The rapid- 
ity of the race toward death, and the accompanying similar tubercu- 
lar infiltration of the meninges and substance of the brain, peritoneum, 
liver, etc., in such cases, leaves little room to question the fact that 
acute tuberculosis is essentially an auto-infective disease. Within the 
last few years a new light has been thrown on the causes and method 
of development of tubercular disorders, concerning which, until 
recently, the views of Buhl as to their origin from autoinoculation 
with caseous matter in the body were generally accepted. This doc- 
trine has been disturbed by the discovery by Koch of the specific bacil- 
lus of tubercle, and by the more recent researches of other patholo- 
gists in the same direction, which enable us in some measure to under- 
stand the extraordinary rapidity with which pulmonary tuberculosis 
too often supervenes on an attack of broncho-pneumonia, particularly 
in strumous patients at the age of puberty. Nor is it to be wondered 
at if, in children thus previously enfeebled by diathesis, the struggle 
for existence between the specific micro-organisms of disease and the 
colorless blood-corpuscles or leucocytes, should so speedily result in 
favor of the almost incredible rapidly-multiplying bacilli, which have 
been so graphically described by Dr. Latham and by Metschinkoff. 

Treatment. — It is said by eminent authors that, be the pathogen- 
esis of tuberculosis what it may, there can be no question of the fact 
that the disease is most generally developed at puberty in the 
patients of an otherwise evidently strumous diathesis, and that its 
primary predisposing cause is generally traceable to malnutrition, gen- 
eral or local, in such cases. Under these circumstances, and bearing 
in mind the facts ascertained by recent investigations just referred to, 
it is obvious that our primary therapeutic efforts should be directed 
toward endeavoring so to enrich or improve the condition of the circu- 
lating fluid as to increase its capability of resisting and destroying the 
micro-organisms by which tuberculosis is developed, and that for this 
purpose we must seek to rectify any existing error of nutrition that 
may result from defective nutriment, as well as from impaired powers 
of digestion and assimilation. These indications should be borne 
practically in view in the selection, for such patients, of a dietary not 
only easy of digestion and assimilation, but also specially rich in those 
elements needed to strengthen the constitution against the inroads of 



Puberty: Its Pathology and Hygiene. 403 

the prolific micro-organisms by which tuberculosis is developed. The 
arrangement of that dietary must, however, be so largely controlled 
by the circumstances of each case that it is impossible to lay down 
any general directions on this point. I may, however, observe that 
some of the special requirements in this respect of strumo-tubercular 
youth are to a large extent supplied by the food-medicines with 
which modem polypharmacy has now armed us for the struggle 
with tubercular disease, wherein pharmaceutic remedies must be 
assigned a place entirely subsidiary to hygienic as well as dietetic man- 
agement, by articles such as cod-liver oil, maltine, and the various 
preparations of malt. 

Prophylaxis of tuberculosis may be either from the point of view 
of the individual already suffering, or from that of the person free 
from the infection. In order to prevent the patient from becoming 
a center of infection and also to diminish the possibility of re-infection 
of himself or herself, the tuberculous person should destroy by burn- 
ing or boiling all discharges from diseased parts, whether such parts 
be internal, as the lungs or bowels, or external, as open glands or 
joints. Local cleanliness is essential, and in phthisis it is important 
that the sputa be not swallowed, but expectorated and immediately 
destroyed. Portable spit-cups are in the market, or small pieces of 
rag may be used, put in a special receptacle, and finally burned. 

Tuberculous subjects should not sleep in the same bed with another 
person, and absolute cleanliness of the person should be enjoined. The 
occupied apartment should have a hard-wood floor, with mats instead 
of carpets, and should be thoroughly scrubbed at short intervals. If 
these precautions are observed, and if the apartment is at all times 
well ventilated, the risk involved in nursing a consumptive will be 
very slight to a healthy person. In a family, however, in which the 
tendency to tuberculosis is strong, the risk is appreciable. 

From the point of view of the non-infected person with an heredi- 
tary tendency to the disease, there are two desiderata: First, to 
increase the nutritive powers of the tissues ; secondly, to avoid infec- 
tion with bacilli. Of these the most important is the first mentioned, 
at least if the individual is to live within the confines of civilization, 
since the tubercle bacillus is so universally present as to make escape 
from it hopeless. At the same time it is important to avoid inocula- 
tion as far as possible, and the person who has a strong hereditary 
tendency to tuberculosis should shun unnecessary exposure to the con- 
tagion; thus a physician should not take a resident position in a con- 
sumptive hospital; a nurse should decline tubercular patients. There 
can be no doubt that, especially in our large cities, there are houses 
and rooms in houses which are infected with the bacillus of tubercu- 
losis. A person with lack of resistive power should never live in a 
room or even in a house which has been occupied by a tubercular patient, 
unless such apartment or house has been cleansed and disinfected in 
a most thorough manner. 



404 Puberty: Its Pathology and Hygiene. 

The child with hereditary feeble resistive powers should, from the 
beginning, be brought up with the purpose of developing the muscu- 
lar and circulatory system, and of obtaining that vitality which is 
given by continuous life in the open air. At the same time it must 
be carefully guarded from the various infectious diseases, especially 
such as measles, which have a tendency to provoke catarrhal inflam- 
mations, and it should be continually watched to prevent the devel- 
opment of mucous-membrane catarrhs, which, experience has shown, 
have a pronounced tendency to aid in the development of tubercu- 
losis. Obstruction of the nose and throat by malformations, adenoid 
gkmds, or enlarged tonsils should be promptly relieved by surgical or 
other treatment, or by the galvanic current of electricity. The cloth- 
ing should be warm, woolen in winter; it is the height of folly to 
attempt to harden a child by insufficient clothing and exposure. 
Habitual cold bathing is excellent in some cases. The food should be 
abundant, simple, and nutritious, largely but not altogether farina- 
ceous, with a full supply of milk, and, if possible, of fats. Almost 
invariably the child can be brought to like cod-liver oil, and advantage 
is gained by making this fat an habitual article of diet in cold weather. 

In selecting a climate the question of degree of temperature is 
said to be a minor one ; that of moisture and equability of temperature 
is dominant. A dry, equable climate is always preferable. Dry cold 
is said not to be dangerous, and is preferable to enervating warmth. 

Prolonged life in high mountainous regions during childhood, if 
associated with habits of exercise, has a tendency to develop the lungs 
and heart, and is very beneficial. When there is any failure in the 
chest development, gymnastic exercises directed to the development 
of this part of the body may be very useful; but no indoor exercise 
will take the place of outdoor work, and it is not probable that any 
artificial system is better than, or even equal to, the natural gymnas- 
tics of an active child. Running up and down mountains, herding 
goats and sheep, following the chase, fishing in mountain streams, — 
these are the methods of restoring vitality to an exhausted family stock. 
It is affirmed by recognized authorities that a long-continued life at 
a high altitude so greatly increases the respiratory movements as to 
cause dilatation of the air-vesicles and a permanent increase in the 
size of the chest, which is a great disadvantage when such persons 
attempt to live at the sea-level. If this be correct, it constitutes no 
reason against bringing up the hereditary feeble upon the mountains, 
but is a strong one for keeping them there during their after adult life. 
The outdoor life is the one dominant feature ; this must be insisted on 
when the individual is forced to take what he can get, not being able 
to get that which is best. 

Returning now to medicinal treatment: Cod-liver oil, small doses 
of arsenic, creosote, carbolic acid, and other drugs, have been admin- 
istered by the mouth; but they seem to have no specific action on the 
tubercular bacillus. "At one time extraordinary hopes were excited by 



Puberty: Its Pathology and Hygiene. 405 

the publications of Koch, — hopes which were, however, entirely beyond 
(as it has proven) what ought to have been reasonably expected from 
Koch's own assertions." 

At present we have no known method of directly attacking the 
bacilli in internal tuberculosis. The indications in the treatment of 
local chronic forms of the disease are, first, to increase the general 
nutrition and the resistive power of the individual, and reduce local 
irritation and changes produced by the bacillus at the seat of infec- 
tion, and to combat constitutional symptoms as they arise. 

THE SUBJECT IX THE EAREY STAGES OF THE DISEASE. 

Parents should seek a climate high and dry, live out-of-doors, and 
sleep in a tent during the warm weather. The food should always be 
simple, thoroughly well cooked, palatable, the most nutritious and 
digestible that can be obtained, with a fair proportion of farinaceous 
articles, very little sugar, and a large amount of fats, as fat mutton 
chops, cream, cod-liver oil, etc. Drink plenty of milk — no tea or coffee 
allowed; but the patient may drink chocolate. It is, however, a mat- 
ter of the utmost importance not to overfeed the patient, — that is not to 
give more food than can be digested. * Sweet-oil can often be taken when 
cod-liver oil does not agree. Alcohol — good whisky — may be considered 
under these circumstances as a food, and is of the greatest value. Taken 
in large quantities, however, it is said, it becomes a deadly poison, but 
taken in tablespoonful doses, with a raw egg, three times in twenty-four 
hours, it is very useful. When the digestion is strong, malt liquors 
are often preferable to spirits ; but when the digestion is feeble, whisky 
or brandy is preferable. Both for physical and moral reasons, the 
alcoholic drink should always be given with the food as a medicine, 
and the impression should be made on the young mind that spirits are 
used as medicines only when it is advisable to do so. A child may be 
given a half an ounce of cod-liver oil in a dessertspoonful of whisky 
after each meal ; an adult may use half an ounce of brandy or whisky 
with the same amount of cod-liver oil after each meal. It is essential 
that the patient be instructed (if she is an adult) never to use stimulants 
against the ever-recurring feeling of exhaustion. Take a cup of hot 
milk, and lie down until the feeling of exhaustion is passed over. 

In prescribing exercise, the point to be borne in mind is that the 
exercise should be regular, day after day, with no paroxysms of excess, 
to be followed by hours of exhaustion. It should never be violent, but 
continuous ; it may be adapted to the individual needs in developing the 
chest or other parts, but always should be, if possible, in the open air, 
and always be kept within the strength of the patient. Slight tiring, 
producing quietness and sleep, is advantageous ; excessive tire is injuri- 
ous. Continuous life in the open air is of the utmost importance, even 
in the advanced stages of phthisis. Life will be protracted and made 
more comfortable by having the bed of the patient on the porch from 



406 Puberty: Its Pathology and Hygi 



ene. 



sunrise to sunset, or in the open air under the shade of the trees, or 
under a canvas or tent, if the temperature is suitable. 

Patients who are past helping should remain at home unless they 
have friends to whom they can go in a suitable climate ; but the consid- 
eration of exposing an uninfected household to the disease should be 
thoroughly discussed, and also how to prevent the disease from becom- 
ing infectious in the household, as has been heretofore described. 

The climate in the eastern United States is that of the Adiron- 
dacks ; Florida is said to be too damp, enervating, and malarious in 
most of its parts for the ordinary case of incipient phthisis. The high 
sand ridge in the center of the state is best situated, so it is said, but is 
probably inferior to the pine district of southern Georgia. The high 
mountainous districts of North Carolina rank next to the Adirondacks, 
and are even superior in those cases in which there is a tendency to 
feebleness. If a patient feels the cold of the Adirondacks, Asheville 
is preferable; or the winters may be passed in Asheville and the sum- 
mers in the Adirondacks. Southern California in some of its parts is 
undoubtedly a good climate, but it is thought or believed to be inferior 
to the central tract in the United States, commencing in San Antonio, 
Texas, and running to Colorado and Arizona. 

The height of the locality above the sea-level is a serious consid- 
eration to the consumptive. Although individual peculiarities here, 
as elsewhere, are important, the majority of tubercular patients will 
do best at a height of from three to six or seven thousand feet above 
the sea. Among the modifying influences in regard to altitude is the 
tendency of the patient to haemoptysis ; when this exists, a rapid ascent 
to a considerable height greatly increases the danger of bleeding. It 
is, though, probable that this is due to the extension of the air-vesicles 
by the increased efforts at respiration produced by the altitude. The 
very cause of the benefit of the altitude becomes the source of danger ; 
therefore, hemorrhagic cases should begin their life in the arid tract at 
a low elevation. Again, in the northern portion of this region, and 
especially in the higher elevations, the cold is severe in winter ; on the 
other hand, in the San Antonio region the summer heat is excessive. 
The selection of a climate depends upon the character of the case and 
the season of the year. In the winter it is usually preferable to send 
the patient to the southern portion, and travel northward with the 
seasons, so that the following winter can be spent in the high and 
colder districts. 

It is of the utmost importance in a case of consumption to main- 
tain the integrity of the digestive apparatus, and in selecting the place 
of abode the possibility of getting properly-cooked food suitable to the 
individual case is of importance. Further, what may be termed 
extraneous considerations often enter into the problem of choice of 
locality. Very frequently the opportunity for making a living, if not 
in the immediate present, in the near future, is of vital importance. 

In Texas, Southern California, Colorado, Wyoming, and other 



Puberty: Its Pathology and Hygiene. 407 

localities, ranch life, or the cultivation of the soil in some way, is open 
to many, and gives work in the open air. In other cases the attrac- 
tions of a city like Denver are dominant. The altitude of San 
Antonio is 6,500 feet; of Santa Fe, which may be looked upon as the 
next important stopping-place, 6,840 feet; of Denver, 5,196 feet; of 
Colorado Springs, 6,000 feet. 

Professor C. B. Penrose, of the Medical Department of the Univer- 
sity of Pennsylvania, spent two years roaming over this arid district, 
and states as the result of his personal observation that a greater pro- 
portion of cases get well in New Mexico than in any other western 
territory or state. The question of the return of the apparently cured 
patient to his home is always a very serious one; in the majority of 
cases permanent residence in a proper climate is most essential. 

Under the second indication — namely, the reduction to the min- 
imum of the local irritation and changes produced by the bacteria — 
may be considered the use of, first, certain pulmonic gymnastics ; sec- 
ond, counter-irritation; third, inhalation, galvanic current of elec- 
tricity; fourth, internal medical remedies, which have already been 
mentioned. 

In cases of incipient phthisis the inhalation of compressed air in 
the so-called "pneumatic cabinet" gives good results, which are prob- 
ably produced by a distention of the air-vesicles. It would seem that 
the results of such inhalations would be inferior to those produced by 
high elevations, and they should be used with great caution where there 
is a tendency to hemorrhage. 

Counter-irritation is often of value in phthisis pulmonalis ; it com- 
bats the local inflammation, but not the bacillus. Croton-oil is pre- 
scribed in the early stages of the disease. When a small amount of 
tuberculosis in the apices produces much irritation, with catarrhal- 
pneumonic consolidation, the continuous use of croton-oil over the 
upper part of the chest may be very serviceable. 

Sinapisms, or dry cups, when there is congestive exacerbation, 
blisters in time of acute pleurisy, liniment of chloroform and oil of 
peppermint when there are neuralgic or muscular pains, — these are 
very useful when judiciously employed. 

The galvanic current of electricity, applied through the tonsils 
and through the bronchials, as has already been prescribed (see article 
on the treatment of bronchial catarrh), relieves the irritable cough of 
phthisis. The writer has relieved many patients while under her care 
till they were able to go to a higher altitude. 

Sometimes sedative expectorants are demanded by the patient to 
"loosen the phlegm;" it is necessary, however, to be guarded in their 
employment, lest the stomach be disturbed. Creosote and guaiacol are 
valuable remedies, especially applicable to cases with very free expec- 
toration; sulphuretted hydrogen terebene and the various expectorant 
volatile oils are useful when there is much chronic catarrh or soften- 
ing. In dry chronic cases with little catarrhal tendency, the long- 



408 Puberty: Its Pathology and Hygiene. 

continued use of small doses of arsenic (one or two drops of Fowler's 
solutions three times a day) may be very advantageous. 

In any case of consumption it is a matter of vital importance to 
study carefully the digestive organs, to adapt the food to the individual 
needs and condition of the patient, and to treat any symptom of 
digestive failure very carefully as soon as it manifests itself. A 
catarrhal state of the stomach and bowels must be met at once by 
appropriate remedies. In the advanced stages, not only comfort but 
also distinct advantage is sometimes obtained by a system of forced 
feeding, consisting of a daily lavage (washing out of the stomach), 
followed by an injection into the stomach of quantities of nutritious, 
concentrated, easily-digested foods. In some cases, in children more 
than in adults, free inunction with cod-liver oil seems to aid in the 
prevention of emaciation. 

When haemoptysis occurs, the patient should be put to bed and 
forbidden to talk or to make any exertion whatever. Opium should 
be given to allay nervous excitement and erethism, which are almost 
invariably present, and to quiet a cough if it should exist. At the time 
of the hemorrhage the taking of a large dessert-spoonful of fine table 
salt into the mouth is sometimes effective in checking the bleeding. A 
thick flannel may be laid over the seat of the bleeding, if it is apical, 
and an ice-bag about half full of pounded ice over the flannel; or a 
towel may be wrung out of very cold water and applied in the same 
manner; then cover the patient so she will not feel cold. If the case 
is severe, fifteen grains of extract of ergot with ten minims of glycerin 
and twenty minims of water, may be given by the stomach, and it 
should be administered hypodermically as well. As ergot is an entirely 
safe remedy, it should be exhibited in large doses. If there is a call 
for immediate haste, two to four fluidrachms of the fluid extract may be 
exhibited at once. Afterward the solid extract should be administered 
in capsules, as less apt to disturb the stomach ; from ten to twenty 
grains (equivalent to five times the amount of the fluid extract) may 
be given every hour to two hours, according to the degree of the 
emergency ; not more than an ounce of the fluid extract of ergot should 
be taken in the twenty-four hours. Gallic acid, which the writer had 
given in capsules, ten grains every two to four hours, was very effi- 
cacious in one case of hemorrhage; oil of erigeron, ten minims every 
one to four hours, is said to be good for hemorrhage. It is a good plan 
to alternate some of these remedies with ergot. If there is excitement 
of the circulation and a full bounding pulse, aconite tincture should be 
administered. Stimulants, such as alcohol and digitalis, in some 
imperative cases have to be resorted to, but they must be very cautiously 
used, lest by increasing the force of the circulation they aggravate the 
hemorrhage. The older remedies, such as sulphuric acid, plumbi 
acetate, oil of turpentine, are of very inferior rank to those above noted. 

Night sweats may occur in the daytime, as sweating is in no way 
peculiar to phthisis. The antihydrotic drugs of value are atropine, 



Puberty: Its Pathology and Hygiene. 409 

extract of ergot, agaricin, gallic acid, and sulphuric acid, named in 
their order of power and general applicability. Of these, atropine has 
the disadvantage in producing great dryness of the mouth and throat 
and disturbance of circulation if given in full doses ; it should be 
given in only one-fourth to one-half doses till the sweating is under 
control during the daytime ; and if there is no day sweating, about two- 
thirds of a dose may be given at bedtime, which will usually stop the 
drenching perspiration. 

From one one-hundred-and-fiftieth of a grain to one two-hundredth 
of a grain may be given once during the day ; or, if the extreme sweat- 
ing exists, the small dose may be given every six hours till relieved of 
the sweating. At bedtime from one-hundredth to one-sixtieth may be 
given, provided there is excessive sweating; otherwise give the smaller 
dose at bedtime also. Extract of ergot does no harm to the patient, 
unless it may disturb digestion, and it may be administered in five- 
grain capsules every four hours during the day. In extreme cases ten 
grains in capsules may be given for one dose every four or six hours 
during the day, as its action is not immediate, like that of atropine, but 
rather continuous. Agaricin is said often to be very efficacious given 
in capsules (three to five grains) every six hours; it has some tendency 
to irritate the intestinal canal, but otherwise it is said to act purely as 
an antihydrotic, exerting no possible influence upon the system. Bath- 
ing the patient at bedtime with alcohol will aid the above remedies in 
checking the sweating. After the sweating the body temperature is 
lowered; frequently it is subnormal. Care should be taken in chang- 
ing the clothing to see that the patient is rapidly dried with a soft, 
warm towel, and to have the fresh underclothes warm beforehand, and 
everything in readiness before commencing to rub the body with warm 
alcohol. Cover each part of the body as it is bathed with clean, warm 
towels, not allowing the patient to be exposed to the temperature. of the 
room (which should, however, be not less than 80 to 90 degrees in the 
winter time, and not less than 70* degrees temperature in the summer 
time) ; and should the patient have a tendency to chill, give two-thirds 
of a dose of atropine before commencing to bathe the patient ; this will 
prevent chilling. Sometimes a tablespoonful of whisky, administered 
just before commencing to remove the wet underclothes, will prevent 
chilling; and if a capsule of quinine (two grains) is administered with 
the whisky, providing the body temperature is below normal, it will 
act very beneficially. Quinine is not effective in consumptive cases, 
except in cases complicated with malaria, which your family physician 
will direct. When all is ready as above advised, go through the process 
of bathing, etc., as quickly as possible. ~No talking should be allowed 
while the patient is being bathed, as time is lost in talking, and the 
patient is being exposed to cold ; do it quickly, so as to avoid the danger 
of taking cold. 

The combating of the hectic fever in phthisis is often hopeless. 
The moderate use of antipyrine, or phenacetine, is sometimes advan- 



410 Puberty: Its Pathology and Hygiene. 

tageous; but never employ large doses if small ones fail, because of 
their tendency to produce depressing sweats. When the temperature 
is high (103 degrees Fahrenheit) a cold sponging or a tepid sponging 
may be employed. 

The writer had one case of laparotomy performed by Dr. S. H. 
Buteau, of Oakland, California, expecting to find a neoplasm of some 
kind; and behold, we found one mass of tuberculosis. Everywhere 
the tubercles could be seen ; they were peeled off, and (they resembled 
a graham gem broken open) rolled out from the peritoneum in masses, 
other physicians witnessing the operation. In the left ovarian region 
tfee tubercles had become broken down, which was causing the con- 
tinued fever the patient had had for weeks and even months before 
she applied at my sanatorium in Oakland, California (Lakeside Sana- 
torium), for treatment. Suffice it to say, the operation was a success 
in every particular. However, for about four weeks the patient had 
a very high temperature, ranging from 102 degrees Farenheit morn- 
ing temperature to 105.7 degrees in the afternoon, with not very much 
variation of the temperature. Though the patient's digestion was 
fairly good, an abundance of fresh milk and eggs was her principal 
nutriment. In nine weeks the patient was sent home. This was five 
years ago; she has since married, and has a fine, healthy-looking boy. 
I will add that Dr. Buteau first closed the wound ; but it did not heal, 
and a drainage tube was put in, and the peritoneum was flushed out 
daily with peroxide of hydrogen, then with sterilized water till healing 
was complete. The writer thinks that laparotomy should be resorted 
to in all cases of tuberculosis of the peritoneum. 

The treatment of intestinal tuberculosis must have for its basis the 
general hygienic management and treatment already specified for 
chronic tuberculosis. Bismuth with carbolic acid, creosote triturates 
(J. Wyeth & Bros.'), chalk mixture containing tannic acid, lead acetate, 
silver nitrate, and other suitable remedies for the relief of intestinal 
catarrh and for the checking of diarrhea when it becomes severe, must 
be used to suit each individual case. Opium is valuable in many cases. 
Externally turpentine stupes, spice plasters, and all the milder counter- 
irritants may be employed upon occasions. The galvanic current of 
electricity gives comfort to the patient, Make the positive pole active, 
place the negative over the spine, and give through the bowels daily, or 
every other day, as strong as the patient can bear it with comfort, usu- 
ally from fifty to eighty milliamperes. Seance from fifteen minutes to 
half an hour. It may be moved about over the bowels .where there is 
tenderness, giving from ten to fifteen minutes' time to each movement 
of the electrode. 

Iodide of iron especially for children in cases of catarrh of the 
bowels (I will add here that all the above-prescribed doses for con- 
sumptive cases are for adults, and children must be given the remedies 
according to the age and constitutional diathesis of the child) is said 



Puberty: Its Pathology and Hygiene. 411 

to be very valuable. The most recent method of treatment is by 
laparotomy. 

Tuberculosis of the kidneys, bladder, prostate glands, seminal 
vesicles, testes, mammary glands, lymph glands, bones, and joints all 
are considered to be surgical disorders, especially to be treated by rad- 
ical local measures when possible. The constitutional management of 
such cases is similar to that of chronic internal tuberculosis. 

In lupus or in scrofuloderma, electrolysis has been used to a con- 
siderable extent with good results when the patches are small. 

GENERAL HYGIENE AND CULTURE OF PUBERTY. 

It would be difficult to overestimate the practical importance of 
the physico-moral management and training of "the springtime of life," 
as this epoch is aptly termed ; for within its limits must be implanted 
the fructifying seeds of health, mental, moral, and physical, by which 
alone the future well-being of the individual may be assured ; or, on the 
other hand, will then be sown the no less potent morbific germs, by 
whose development the sanitary integrity of mind and body must 
eventually be impaired or destroyed. 

The pathological influence of the course of puberty of some of the 
latter agencies was well described by Dr. James Johnson, of London, 
in his "Economy of Health," in which he says : "In this stage of rapid 
development, corporal and mental, the greatest difficulty is experienced 
in preserving the physique within the bounds of health, and confining 
the morals within the limits of virtue. How many minds are wrecked, 
how many constitutions ruined, during the third septennial ! At so 
early a period of life, when passions so predominate over principles, it 
is hardly to be expected that the force of precept can be so efficient a 
preventive as the fear of bodily suffering. If the youth of both sexes 
could see through the vista of the future years, and there behold the 
catalogue of afflictions and sufferings inseparable attendants on time 
and humanity, they would pause ere they added to the number by 
originating maladies at a period when nature is endeavoring to fortify 
the material fabric against the influence of those that must necessarily 
assail us in the progress of life. Yet it is in this very epoch that some 
of the most deadly seeds of vice and disease are implanted in our spir- 
itual and corporeal constitution, — seeds which not merely 'grow with 
our growth and strengthen with our strength,' but acquire vigor from 
our weakness and obtain victory in our decay. This melancholy reflec- 
tion is applicable to all classes and both sexes. The sedentary and 
insanitary avocation to which young people of both sexes in the middle 
and lower classes of society are confined, between the ages of fourteen 
and twenty-one, occasions dreadful havoc in health and no small 
deterioration of morals. 

"The drudgery, scanty clothing, bad food, and exposure to the ele- 
ments, of our laboring or factory population, as well as the still greater 



412 Puberty: Its Pathology and Hygiene. 

miseries of the too numerous unemployed poor in these countries, are 
but little more injurious to health and life than the sedentary habits, 
unsanitary suroundings, and depressing passions of the various species 
of artisans, mechanics, and shopkeepers in the classes immediately 
above them. The infinite variety of new avocations among these grades 
has given rise to a corresponding infinity of physical and moral mal- 
adies, of which our forefathers were ignorant, and for which it requires 
much ingenuity at present to invent significant names. The incal- 
culable numbers of young females confined to sedentary avocations from 
morning to night, and too often from night till morning, become not 
only unhealthy themselves, but afterward consign debility and disease 
to their unfortunate offspring. It is thus that infirmities of body and 
mind are acquired, multiplied, transmitted from parent to progeny, and 
consequently perpetuated in society. He would be blind indeed who 
did not perceive the outward working of the causes in our own day. 
Nations are only aggregations of individuals, and whatever be the 
influence, whether good or evil, that operates on a considerable number 
of the population, that influence will radiate from ten thousand 
centers, and diffuse its effects, sooner or later, over the whole surface 
of the community." 

In viewing the ascending links of society at this present time, there 
is no great cause for congratulation. The youth of both sexes, doomed 
to the counter, the desk, and the schoolroom, are little elevated, in point 
of salubrity, above their humbler contemporaries. It is during puberty 
that the destiny of youth is fixed for all the various professions and 
pursuits, into the training for which the young are now too often pre- 
maturely forced by the increasing exigencies of the struggle for exist- 
ence, wealth, or distinction in all densely-crowded centers of population. 
What wonder, then, that under such circumstances the intellectual 
advantages thus secured are too dearly purchased at the expense of 
health ? The physical stamina as well as the mental powers are too fre- 
quently thus so overstrained in this fierce competition that both thereby 
become prematurely exhausted, and if not permanently at least tem- 
porarily debilitated and incapacitated for their ordinary functions. 
These results are, moreover, very commonly consequent on errors in 
the mental or physical training of children in the period immediately 
antecedent to puberty, the result of which, being manifest at this epoch, 
must be here referred to. 

"The mental training or education [quoted from Dr. Badden] 
of youth during early puberty is a question always of great importance, 
but of special interest at the present time. We are all, of course, 
agreed as to the duty of suitably educating the young, so as to fit them 
for the daily-increasing requirements and competition of modern life ; 
but as to the extent to which this should be carried out in early child- 
hood, there is, unfortunately, a great discrepancy between the doctrin- 
aires of the educational department and the views of those who have a 
knowledge of the laws of nature, or who, as physicians, have to deal in 



Puberty: Its Pathology and Hygiene. 413 

disease, with the consequences of their violation. The 'red-tape official- 
ism' of the former is often supreme over medical experience. And, 
hence, whilst children, before the age of puberty, are thereby over- 
worked into disease or death, the physicians must still raise their pro- 
testing voice. 

"The first years of life should be mainly occupied by moral and 
physical training, and during this period the amount of mental culti- 
vation which a child's brain is capable of receiving with permanent 
advantage is much less than is commonly believed. No greater 
physiological mistake is possible than the prevailing idea of attempting 
any considerable degree of mental culture until sufficient development 
of the physical stamina and moral faculties is accomplished. The 
organs of the mind are as much a part of the body as the hands and 
feet, and ere either can function properly, its vital force must be devel- 
oped and maintained by nutrition. Hence arises a very important 
practical question in connection with compulsory elementary education. 
A large proportion of those who must come within the provision of the 
law in most cities are ill-fed children of the poorest classes, and are 
those with whom for the past sixteen years we have had to deal daily 
in the hospital for sick children. As a matter of fact, we may accord- 
ingly observe that children thus debilitated by privation are necessarily 
as much incapacitated for any mental strain as they are for the accom- 
plishment of any feat of physical strength, and that it is as inhuman, 
injudicious, and impolitic to expect the former as it would be to look 
for the latter from those so circumstanced. 

"If, therefore, the state, for reasons of public policy, determines 
that all children shall be compulsorily educated from the earliest years, 
it should certainly afford the means by which this may be least inju- 
riously and most effectually carried out by providing sufficient food, as 
well as education, for every pauper child compelled to attend school." 

Among the results of overpressure in schools referred to in Sir, 
Crichton Browne's admirable report on the subject, are "cerebral dis- 
eases in all forms, viz., cephalitis, cerebritis, meningitis, as well as 
headache, sleeplessness, neurosis of every kind, and other evidences of 
cerebro-nervous disorders. It would be difficult to overestimate the 
pathological consequences of thus directing all the available energies 
of the system to the brain during early youth, to the irreparable injury 
of the overstimulated cerebral organization, and at the expense of the 
other functions and organs of the body. Time, however, does not per- 
mit of our dwelling on the ill effects of mental overpressure brought 
under our own observation. We now allude to this subject merely with 
the view of pointing out the imminence of the danger and the impor- 
tance of its avoidance." 

The deterioration of the physical stamina is thus due, as we may 
say, mainly to the fact that a large part of the first years of life, which 
should be primarily devoted to religious or moral as well as physical 
training, is now given up to the development of the mental powers. The 



414 Puberty: Its Pathology and Hygiene. 

child is too early compelled to attend some school, where the immature 
brain is forced into abnormal and disastrous activity. It is to be 
hoped that the system of kindergarten now so much in vogue in this 
country, and the wonderful strides which have been made in physical 
training, even in our elementary schools, will have the effect of reducing 
the death-rate from cerebral diseases in childhood, and will aid in giv- 
ing our youths of both sexes sound minds in sound bodies. 

ILL RESULTS OF SEXUAL PRECOCITY DURING PUBERTY. 

Dr. Badden and others have observed that in no particular are the 
pathological effects of the killing pace at which the race of life is 
nowadays too often run, from its start to its untimely finish, more 
apparent than the premature breakdown of constitutions consequent 
on the abnormally precocious indulgence or abuse of the sexual instinct 
or appetite. To these abuses is unquestionably due a large and increas- 
ing proportion of the many maladies by which the course of after life 
is embittered or its duration shortened. 

What I particularly refer to are those remote or secondary consti- 
tutional effects of precocity which must be familiar to every experienced 
physician, who, in almost daily practise, may encounter the wretched, 
cachectic, and mentally as well as physically debilitated victims of 
early erotic excesses or abuses. To these causes must, we fear, be 
largely ascribed the failure of physical stamina as well as that nervous 
hypersesthetic condition and lamentable lack of mental power and deter- 
mination of character too often noticeable among youths of the present 
day, and which clearly mark "the Nemesis of a widespread epidemic 
of precocious sensuality." The means by which this epidemic may be 
best mitigated is through the mothers. The women physicians, and 
women who are ministers of the gospel, need to be awakened to the 
fact that it does lie within their power to teach mothers that these evils 
are caused through ignorance of mothers and their indifference to the 
welfare of their children. They are not watchful to see whether they 
are moral, or whether they are forming the habit of self-abuse in very 
early life. As we have heretofore remarked, mothers should teach 
their children to tell them when they feel uncomfortable about their 
genitals, and mothers should be vigilant to see that their children are 
kept clean. Little girls should be washed every night between the 
labias before they are put to sleep, thus preventing any irritation. The 
mothers should ever be watchful of their children's playmates, whether 
or not they use immoral language; they should be taught in early life 
not to associate with bad children. The writer has observed that it is 
not a good plan for little boys and girls to become intimately acquainted 
from constant association. Little girls should play by themselves, and 
little boys likewise. The writer believes that what has been written in 
these pages is sufficient for all mothers to be profited by it, and that 
they will look to the very early training of their children against all 



Puberty: Its Pathology and Hygiene. 415 

immoral vices, each mother in her own special method, as each child 
has to be approached and instructed according to his understanding, 
some children being more precocious than others. 

As I have said before, in a large majority of cases where little 
boys form the habit of masturbation, it is due to the lack of proper care 
in early life. The child may have stricture of the foreskin (phymosis), 
causing an irritation; hence the habit of scratching is formed, and it 
is due to itching of the parts. Also so-called "pinworms" or "seat- 
worms" will cause an irritation in both sexes, also diabetic urine will 
cause it. If a little boy has stricture, circumcision is the cure. The 
mother's moral training from birth is the only hope of ever stamping- 
out vice. The purity of a true, loving mother's training is far-reaching, 
and when she is fully aware of this fact from a scientific stand- 
point, and each mother is looking to the welfare of her own children, 
we can see, with the knowledge she has obtained, that in a very few 
years, vice and immorality will fade away through the means of home 
training. Dr. Baden says that ''the treatment of vice is beyond the 
reach of the physician, and belongs rather to the domain of the moral 
teacher or the minister of religion." 

CONSEQUENCES OF ABUSES OF ALCOHOL AND TOBACCO DURING PUBERTY. 

Another phase of the too common untimely abridgement of early 
puberty by precocious indulgence in the habits and vices of adult life, 
is exemplified by the painful results of juvenile drunkenness, daily 
witnessed, especially among the neglected children of the streets. Dur- 
ing, and even before, the first stages of puberty, children are forced 
into the thoroughfares of our great cities, there to eke out a living the 
best they can ; and the pathological consequences of their acquired or 
inherited alcoholism are brought under clinical observation in the form 
of gastric and hepatic disorders and especially cirrhosis of the liver, 
as well as in the protean forms of cerebro-spinal disease, and the various 
neuroses which are so frequently noticed in hospitals for children. 

The evils thus resulting from the prevailing intemperance of the 
young as well as the old, should induce us to warn those whom our 
counsels may influence against the custom of giving alcoholic stimulants 
to children, — a custom which is so general in its practise and so calam- 
itous in its results. Even in those exceptional cases in which such 
stimulants may be necessary, we should never sanction their adminis- 
tration save under a guise and in the definite doses of other remedial 
agents. It is physiologically wrong as well as morally unjustifiable 
ever to allow a healthy youth to taste alcohol in any form. 

With regard to the use of tobacco, authors are agreed that the 
effects of nicotine are most injurious to youth at the age of puberty. 
Parents should look after the early training of young boys against the 
use of tobacco. 



416 Puberty: Its Pathology and Hygiene. 

SPECIAL HYGIENE AND CULTURE OF FEMALE PUBERTY ; ITS PRACTICAL 

IMPORTANCE. 

In a previous section we have described the special functional 
disorders incident to female puberty, and must now refer to other cer- 
tain causes of those various nervous and constitutional ailments that 
are prevalent during this period. Of these causes some, although of 
a moral rather than of a physical character, • are yet so intimately con- 
nected with the production and course of the complaints referred to 
as to demand a brief notice. 

% Among the subjects thus included in this connection are the influ- 
ences on female health in puberty of the mental, moral, and physical 
training or education during, or immediately before, this period; the 
ill effects of the customary modes of dress and habits and occupations 
of girls at this time ; also the results of premature or abnormal stimu- 
lation of the sexual system, whether by too early marital life or in any 
other way, at that age. 

Dr. Johnson says that "female life at any period is fully as good 
in respect to probable duration, as that of the male, perhaps even a 
little better." The writer heard an eminent gynaecologist say very 
recently — one who is accustomed to operating almost daily upon 
women — "You can't kill a woman; she is like a cat, — has nine lives. 7 ' 

"It is in the period of puberty that the seeds of female disease 
are chiefly sown, or at least that the soil is specially prepared for their 
reception and growth. The predisposition to infirmities and dis- 
orders of various kinds is affected by acts of omission and commission, 
in the first class being included the deficiency of healthy exercise of 
the body in the open air, and of intellectual exercise in judicious 
studies. The ill results of these are perhaps most apparent among 
young girls of the upper classes of society. 

"The increasing exigencies of modern life, and the desire to ren- 
der girls accomplished at all hazards, have originated a system of 
forced mental training, which greatly increases the irritability of the 
brain, whilst at the same time sedentary employments are followed, 
frequently as amusements, to the exclusion of active, outdoor exercise. 
The slow but powerful influence of music, dancing, vivid colors, and 
odors on the nervous system, but especially on the reproductive sys- 
tem, are quite overlooked. Many more hours of severe application 
are occupied in the acquisition of pieces of music, which are forgotten 
as soon as possible after marriage, when muisc would be least hurtful, 
or rather, most useful. Dr. J. Johnson very justly asks, "Is it prob- 
able that so potent an excitant as music can be applied daily for many 
hours to the sensitive system of female youth with impunity ?" 

The same writer points out that "the stimulus of music is of a very 
subtle and diffusible nature, and the excitement which it produces in 
the nervous system is of a peculiar character, and one by no means 
generally understood." Accordingly, any excessive exposure to this 



Puberty: Its Pathology and Hygiene. 417 

potent stimulation is liable to be productive of some of the various 
hyperesthesia morbid conditions of mind and body so prevalent dur- 
ing the period of female puberty. Dr. Johnson says: "Excessive 
attention given to music in female education is, moreover, indirectly 
hurtful by not leaving sufficient time for other and more serviceable 
employments of mind and body, by which the former may be strength- 
ened against the vicissitudes of fortune and the moral crosses to which 
female life is doomed, nor healthful physical exercise, by which the 
material fabric may be fortified against the many causes of disease 
continually assailing it. The consequence of all this is that the 
young girl too often returns from school to her home an hysterical, 
wayward, capricious girl, imbecile in mind, habits, and pursuits, 
prone to hysteric paroxysms upon any excessive mental excitement. 
This, I may add, appears very liable to be superinduced by the per- 
nicious novels of the erotic and sensational school which are the pop- 
ular literature of young females, and by which the impressionable 
jnind of girlhood is perverted, the passions stimulated, and the founda- 
tions laid for the future development of various morbid conditions of 
mind and body, and more especially erotomania and nymphomania. 

"I shall only repeat that it may be regarded as an exaggeration 
of the peculiar sentimentality which is generally inherent in female 
youth, and which is usually so evanescent as to require little if any 
medical attention. In some instances, however, this excess of natural 
sentiment is of graver consequences, the mind becoming so occupied by 
its predominant illusion as to impair, more or less completely and 
permanently, the exercise of the rational faculties, and not alone pro- 
duce mental derangement, but also react injuriously on the general 
health and more especially on the utero-ovarian functions of the love- 
sick girl. Instances of this kind are familiar to nearly all prac- 
titioners. There are few among us who have not been consulted by 
some anxious mother, alarmed at symptoms of mental dejection and 
nervous or mental functional disturbances, for which no physical 
cause can be discovered, arising from cardiac causes beyond stetho- 
scopic diagnosis. This condition is, in its inception, entirely dis- 
tinct from erotomania, but if allowed to develop unchecked may in 
some instances ultimately result in the latter." 

The influence of dress is great on the physical health of young 
girls. All that has been written upon this subject by various writers 
has apparently been nil. The two important points to be here borne 
in mind with reference to female clothing, are, first, that the material 
should be such as may serve to retain the necessary animal warmth; 
and, secondly, that its form should be so arranged as to occasion neither 
undue visceral compression, nor any interference with muscular action. 
Hence, whatever little influence we may exercise in the matter in the 
way of advice is at this epoch to adopt the use of flannel or merino 
underclothing, all-woolen fabric, discard compressing corsets for cor- 
set waists with shoulder straps, beware of high-heeled boots and 

27 



418 Puberty: Its Pathology and Hygiene. 

tightly-fitting corsets, by which young ladies seek to reduce their nat- 
ural proportions, however robust, and at whatever cost of comfort or 
health, within the prescribed limits of "the pink of fashion and the 
mould of form." This advice we should give when the occasion offers, 
but the good advice of physicians is seldom followed, for in such mat- 
ters fashion and the modiste will probably continue to the end of the 
chapter reigning triumphant over common sense and the doctor. 

The injurious consequences of the absurd modes prevalent in the 
dress of young girls are exemplified in the effects of tight lacing on the 
pulmonary functions, for the normal accomplishment of which free 
expansion of the chest and unimpeded action of all the muscles con- 
nected with respiration are so essential. The results of errors of this 
kind are most apparent at the period of puberty, when the young 
lady exchanges the comparatively easy garb of girlhood for that 
imposed by the requirements of fashionable life. And these errors 
reach their extreme in the attire of the ballroom or theater, or what 
"on the lucus a non lucendo principle is now regarded as full dress. " 
"At these assemblies," Dr. Barlow has well observed, "the tightly-laced 
stays, the exposed chest, and thin draperies furnish a combination of 
influences the combined effects of which no constitution could with- 
stand ; while to these is yet to be added that of respiring for hours in a 
heated and vitiated atmosphere, and after this, of passing, when relaxed 
and exhausted, into the cold current of a frosty night air. So, far 
from wondering that many suffer from these imprudences, our surprise 
should be that any escape ; and instead of the inherent delicacy so often 
imputed to the constitution of females as explanatory of their peculiar 
ailments, we have ample proof, in their power of resisting such noxious 
influences, that they possess conservative energies not inferior to those 
of the most robust men. Were men to be so laced, so imperfectly 
exercised, so inadequately clothed, so suffocated, so exposed, their 
superiority of bodily vigor would soon cease to have any existence. 

"Defect of clothing, though most signal in the chest and shoulders, 
is not confined to the upper part of the body. The feet require 
warmth, which subservience to fashion prevents; they can not be com- 
pressed, but at the cost of much suffering, some distortion, and the 
infliction of positive disease. Fashion also permits the legs to be 
covered with only the thinnest material. Thus the capillary circula- 
tion of the feet, rendered sufficiently languid by the general weakness, 
becomes further impeded by the pressure of tight shoes and the debil- 
itating effects of cold. The crippled state, too, thus occasioned is a 
further obstacle to efficient exercise, and so adds to the general debility." 

General Treatment of Nervous Disorders of Female Puberty. — 
We will notice the most important points in the treatment which 
appears to me to be the most applicable to the management of the 
ordinary forms or phases of hysterical disease at ,this period. 

First of all, the treatment should begin from birth. All hys- 
terical mothers (some fathers, too, for that matter) should begin 



Puberty: Its Pathology and Hygiene. 419 

from early life to train the child, not allowing any irritation to exist 
abont the genitals ; give the child light, nutritions diet at night ; put it 
to bed early ; never whip a child at night, or even scold one severely, as 
it will almost invariably cause disturbed sleep, which is calculated to 
help or develop hysteria in a child who has a hereditary tendency. 
Greet your child with a merry good-morning; give him a wholesome' 
breakfast of milk with the cream on it, a raw egg or a very soft-boiled 
egg, or well-cooked oatmeal mush, or a warm roll with fresh butter, 
not stale or packed butter, as it is poorly assimilated, and is unfit for 
children; no coffee nor tea; if they ask for either, give a cup of hot 
milk with a little tea or coffee in the milk. In cities some children 
will make a meal of toast for their breakfast, and go to school and 
work till noon with nothing else ; in children thus fed you may expect 
a nervous breakdown, especially those who have a weak constitution. 
Provide pleasant and healthy exercise for your children. Parents 
should enter into the amusements of their children, taking at all times 
an interest in answering questions propounded by the children. They 
are developing; their minds are unfolding; and they are wondering 
what is the meaning of what they see and hear. They should be care- 
fully taught by their own parents ; and if mothers will study the 
peculiarities of each one of their children, and train each according 
to his or her disposition (no two in a family are alike), they can thus 
aid nature in developing their daughters out of hysterical tendencies 
by the time they arrive at the age of puberty. 

Boys should also have equal consideration in all these particulars, 
in order that they may grow up to be strong, vigorous men. 

The curative effects of change of climate and the utility of chalyb- 
eate and other mineral and thermal waters, though obvious in all 
chronic diseases, are in none so essential as in the nervous and hys- 
terical disorders of puberty. In such cases by a trip to the country, 
and, where the parents can afford it, a journey to a foreign and distant 
health resort, the patient is given the benefit of change of climate, 
occupation, and mode of living. The new scenes and places, with 
variety of climate, suggest new thoughts, by which the attention of 
the hysterical girl is diverted from morbid fancies and exaggerated 
sensations, until at length, by ceasing to dwell on her self-created com- 
plaints, they gradually cease to trouble her. 

Foremost among the remedies by which we may hope to allay 
the perverted molecular activity of the nerve centers in the hysterical 
disorders of puberty, is the galvanic and f aradic currents of electricity 
properly applied by an experienced physician or specialist. This, in 
the writer's opinion, will do more toward tiding the hysterical patient 
over that epoch than all the other therapeutical remedies combined. 
However, such treatment is often unavailable, hence we have to have 
recourse to medicinal agencies. The various special nerve sedatives 
are different bromides and the valerianates of quinine and zinc. Mere 
hypnotics are of little value, and narcotics, more particularly opium 



420 Puberty : Its Pathology aad Hygiene. 

and its alkaloids, are worse than nseless for this purpose. We must 
seek to remove any local disease or to restore any disordered function 
of which the hysterical disturbance may be the result; but in doing 
this we should be careful to avoid the imminent possibility of increas- 
ing whatever vaginal, uterine, or ovarian hyperesthesia may be pres- 
ent by any topical examination and treatment that is not absolutely 
necessary. We must insist on healthy occupation of the mind and 
body, and fit the latter for this by the appropriate remedies called for 
by the special requirements of each case. If the nervous derangement 
is^ consequent on disordered menstruation, this condition must, if pos- 
sible, be rectified. If it results from premature or undue stimulation 
of the sexual organs, the physician should point out distinctly the 
physical and moral evils consequent on such abuses. 

In conclusion, it only remains for me to add that in the fore- 
going attempt to describe the many-sided medical aspects of the epoch 
of puberty, and quoting freely from eminent authors upon this sub- 
ject, I am actuated by the hope that this may be the means of help- 
ing all mothers in their noble and godlike work to bring up their 
children to full maturity, strong, healthy, and vigorous. 



CHAPTER XXV. 
FEVERS AND MIASMATIC DISEASES. 

Definition and Nature. — The term "fevers" is used in its widest 
sense, denoting a complexity of symptoms, or group of symptoms, of 
which heightened temperature is the most striking and the most con- 
stant. 

Disorder, then, of the body heat, in the direction of increase, is 
the essential condition of fever. We quote from William Pasteur: 
"In health the maintenance of a normal temperature involves three 
cooperant factors, — a source of heat, channels for the discharge of 
heat, and regular mechanism which shall maintain a stable balance 
between heat production and heat loss. Owing to the integrity of this 
mechanism, any variations in heat production are immediately com- 
pensated by concurrent variations in heat discharge, so that the tem- 
perature of the body as a whole is not appreciably affected. It has 
been shown experimentally that during fever the variations of the two 
processes are no longer interdependent, — that the regulating mechan- 
ism is out of gear. In consequence of this the rates of heat produc- 
tion and heat loss vary irregularly, so that the elevation of temper- 
ature can not be regarded as a true measure, either of increase of the 
former or of diminution of the latter. Under circumstances deter- 
mining a diminution of heat loss, a high temperature may coexist with 
a low rate of heat production ; and, conversely, if heat is being rapidly 
parted with, there may be a considerable increase of heat production 
without any commensurate elevation of temperature. So that we must 
conclude that while the clinical ■ thermometer affords unmistakable 
evidence of some derangement of the heat-maintaining apparatus, it 
throws little or no light on the nature or direction of the disturbance. 
In fever, as in health, the source of heat is the same, at least in kind." 

It is stated with admirable clearness by Professor Forester: "We 
may at once affirm that the heat of the body is generated by the oxidiza- 
tion, not of any particular substance, but of the tissues at large. 
Wherever metabolism or protoplasm is going on, heat is being set 
free. ... In growth and in repair, in the disposition of new 
material, in the transformation of lifeless pabulum into living tissue, 
in the constructive metabolism of the body, heat may be undoubtedly 
to a certain extent absorbed and rendered latent ; the energy of the 
construction may be in part, at least, supplied by the heat present. 

"But all this, and more than this, — namely, the heat present in a 
pontential form in the substances so built up into the tissue, — is lost 

(421) 



422 Fevers and Miasmatic Diseases. 

to the tissues during its destructive metabolism; so that the whole 
metabolism, the whole cycle of changes from the lifeless pabulum 
through the living tissue back to the lifeless product of vital action, is 
eminently a source of heat." "Thus it is in increased destructive 
metabolism that we must look for the origin of fever-heat, and its 
chief seat is the muscles. In health it is estimated that they yield 
four-fifths of the whole body heat, and in fever their relative contri- 
bution is probably larger. Both clinical and pathological observations 
bear witness to the profound manner in which they are affected. 
Among these may be mentioned the characteristic pains and weakness, 
tlje marked wasting often so striking in the fevers of children, and the 
associated increase of the salts of potash, of urea, and of other nitrog- 
enous substances in the urine." 

The channels for the dissipation of heat are the skin, by radia- 
tion, conduction, and evaporation; and the lungs, by evaporation and 
warming of the expired air. As sweating is not so common in the 
fevers of children, evaporation necessarily plays a less-important role 
than in the fevers of adults. The pungency of the skin, which is often 
met with, may be partly due to this peculiarity. It is usually asso- 
ciated with a preternaturally dry skin and contracted cutaneous vessels, 
conditions which tend to prevent a rapid loss of heat, and therefore 
favor elevation of the surface temperature. We are all familiar with 
the remarkable way in which the aspect and feeling of the skin may 
vary during an attack of simple fever. In less than an hour a pale, 
dry, pungent skin may become flushed and moist. A febrile blush 
so intense as to arouse suspicion of an acute exanthema may vanish 
altogether in a few minutes. We see by these facts that heat dis- 
charge is largely under control of the nervous system, acting through 
the vasomotor nerves; but they also point with equal emphasis to the 
profound disturbance of that control. It is found that radiation 
increases steadily as the temperature falls, until a certain limit is 
reached; that it varies directly with the activity of the process of 
nutrition and metabolism, and is therefore more active in children 
than in adults ; and it is said further, there is some ground for believ- 
ing that it is subject to nervous control. These conditions call for 
light covering and cool, well- ventilated sick-rooms. 

Causes of Fever. — It is almost impossible to formulate a classi- 
fication of the causes of fever, which shall be at once simple and com- 
prehensive. Experimental investigation on ferments and putrid intox- 
icants have thrown much light on the nature of inflammatory fever. 
But the nature of the relationship of many of the acute specific febrile 
diseases to the invasion and multiplication within the body of patho- 
genic micro-organisms still remains to be solved. In common with 
ferments and putrid intoxicants, the poisons of the majority of these 
diseases exert a pyrogenic effect after being received into the circula- 
tion. Their precise mode of action is still a matter for speculation. 



Fevers and Miasmatic Diseases. 423 

It may be possible that all pyrogenic substances act by producing a 
common change in the body. 

The first group of fever-producing agents comprises substances 
which, if not actually identical with physiological ferments, are readily 
produced by them independently of the action of bacteria. Some of 
them are normally present in small amount in the body ; others may be 
produced in the disintegration of extravasated blood or by the abnormal 
disintegration of tissue, and if absorbed in sufficient quantity or under 
suitable conditions, are held to be the cause of the febrile state known as 
ferment intoxications. As probably members of this group, may be 
cited cases called aseptic fever, following extensive injuries or lacera- 
tions in spite of rigorous antiseptic precautions, and the febrile reaction 
attending subcutaneous injuries and extravasations, especially frac- 
tures of large bones. It is probable that the pyrexia which accom- 
panies certain forms of anaemia, and possibly some obscure varieties 
of simple fever, also belong to this category. 

The second group comprises substances which are the product of 
micro-organisms not in themselves pathogenic, that is, not capable of 
further multiplications when inoculated in pure cultivation into the 
body. Their presence in foul wounds leads to the formation of chem- 
ical substances, which, when absorbed into the circulation, give rise 
to pyrexia with toxic symptoms, — putrid intoxication. Under this 
head are included the febrile state, which subsides after the thorough 
cleansing of a foul wound, and the whole class of septic fevers, which 
result from absorption of poisonous substances produced in necrotic 
or disintegrating tissues or exudations, or extravasated blood, by the 
action of purely saprophytic bacteria. Of this nature are probably 
also the secondary fever of variola, and, in part at least, the fever of 
typhoid after the end of the second week. 

Fermentative and putrefactive bacteria are normally present in 
the alimentary canal, and it is probable that under certain circum- 
stances the products of their activity may, by their absorption, give 
rise to febrile attacks, which are, however, for the most part, of a 
milder type than those just mentioned. 

Of far graver significance are the putrid intoxications which result 
from ingestion of substances which, outside the body, have undergone 
putrefaction, or changes which lead to the formation of ptomaines. 
Some of them appear to be harmless, but the introduction of others 
into the circulation is attended with pyrexia with toxic symptoms. 
They may be^ absent in advanced decomposition, and in general the 
most virulent ptomaines are formed in the earliest stages of putrefac- 
tion. There are also differences in the kind of bacteria present, 
according to the nature of the substances decomposed, and to various 
other circumstances, such as the presence of oxygen, the temperature, 
etc. Of this nature are some of the cases of poisoning which have been 
caused by eating unsound meat, fish, cheese, etc. The absorption of 
poisons of a similar kind, not necessarily the product of pathogenic 



424 Fevers and Miasmatic Diseases. 

bacteria, such as is met with in cases of diphtheria and hospital sore 
throat, produce the constitutional disturbance which is not uncommon 
in scarlet fever toward the end of the third week, in association with 
the onset of nephritis. 

In the third group are included the poisons of the acute specific 
febrile diseases. Of them we know that they are specific, i. e., that 
the disease which they produce, and of which pyrexia is a constant con- 
comitant, never pass the one into the other; that they prevail epi- 
demically or endemically; that they are in large proportion infectious 
or contagious; that they may gain admission to the body by various 
routes, some by inoculation, some by the respiratory mucous membrane, 
some by the gastro-intestinal tract. The nature of many of these poi- 
sons is said to be still uncertain. 

Significance of Heightened Temperature in Children. — The tem- 
perature of children in health is characterized by a relative instability 
which renders it liable to disturbance by a variety of causes, many of 
them of the most trivial nature. This is to be accounted for partly 
by the undeveloped state of the nervous system, partly by its state of 
active growth. Almost a mere nothing will send an infant into a high 
fever ; a very little restores it again to health. But as the child grows, 
its temperature becomes less liable to disturbance, until with years it 
gradually acquires the stability which distinguishes the temperature 
of adults. 

The readiness with which physiological tissue activity in a child 
gives place to a pathological activity in the presence of disturbing 
causes, is also a reason why fever is a frequent concomitant of disease 
in children. As examples of their tendency may be mentioned acute 
lymphadenitis, that common cause of fever, and the proneness of 
inflammation to issue in suppuration. In the same way instability is 
the key-note to the peculiarities of febrile temperature of children. 
It contrasts with the pyrexia of adults, less on account of any differ- 
ence in range and height than because of its striking tendency to pre- 
sent sudden and temporary remissions. It may rise and fall several 
times in twenty-four hours. Periods of high and low temperature may 
alternate in the most uneven and irregular manner. A trivial cause 
may send the temperature to 104 degrees Fahrenheit, or even higher, 
without apparent discomfort to the patient, whereas a fatal case of 
pneumonia may run its course without the temperature exceeding 
102 degrees Fahrenheit. 

In young children and infants it is best to take the temperature 
in the rectum or in the groin. In older children it may be taken in 
the mouth, or axilla. The rectal temperature is about 70 degrees 
Fahrenheit higher than in the axilla, and 50 degrees Fahrenheit higher 
than that in the mouth. 

The following criteria have been laid down on the significance of 
pyrexia in children : "The pyrexia is good which is lower in the morn- 
ing than in the evening; which is equal or with but slight variations 



Fevers and Miasmatic Diseases. 425 

during the day ; which has a single rise and a single fall in the twenty- 
four hours; and whose lowest morning level approaches the normal 
line. The pyrexia is bad which is highest in the morning; which 
ascends from evening through all hours ; which has two or more rises 
or falls for one day and night; which either maintains its level above 
103 degrees Fahrenheit pretty equally for many hours together, or else 
is very variable from day to day and conformable to no pattern. The 
temperature register gives the first warning of impending mischief 
after injuries and surgical operations; it supplies our sole means of 
watching and of measuring hyperpyrexia; and in conjunction with 
other signs (by no means by itself) it helps to distinguish certain 
fevers, and to estimate their progress and severity. These latter, how- 
ever, are but occasional uses." (Sturges.) 

Stages and Types of Pyrexia. — Three stages are generally recog- 
nized : the initial stage, that of rising temperature ; the elevation, or 
stage of sustained high temperature; and defervescence, during which 
the temperature returns to the normal level. The duration and pat- 
tern of each stage vary considerably in different diseases, and in the 
same disease according to circumstances. A rapid and continuous rise 
is the rule in scarlet fever and ague, while in measles and typhoid 
fever the rise is more gradual and often broken by a series of remis- 
sions. Crisis is the more common mode of defervescence. The actual 
crisis may be preceded by one or more sharp and deep remissions ; this 
is sometimes the case in acute pneumonia. Typhoid fever affords a 
good example of defervescence by lysis. After defervescence, the tem- 
perature is often subnormal for a few days ; and during convalescence 
it is characterized by its greater instability, and liability to disturbance 
by causes which would make little or no impression on the temperature 
of a healthy child. 

In the terms continued, remittent, and intermittent, which are still 
in common use, we have a survival of the nomenclature of an age in 
which fever was regarded as a disease — a morbid entity — presenting 
different types. At the present time these terms are used to qualify 
the pattern of a pyrexia, rather than as a basis of classification. They 
are too well known to need special description. The remittent type is 
especially common in the fevers of children. Hectic fever is the name 
given to the remittent or intermittent fever which occurs in some wast- 
ing diseases, more especially when these are accompanied by chronic 
suppuration with profuse discharge of pus. It is often present in pul- 
monary and abdominal tuberculosis with or without ulceration. In 
the early stages there may be intermissions during the day, with febrile 
disturbances toward evening. As the disease progresses, the fever 
assumes a remittent type, with exacerbations at night and perhaps in 
the morning. The rise and fall of temperature may be preceded by 
chilliness and end in a profuse sweat, especially about the head and 
shoulders. 

Symptoms of Fever. — Prodromal symptoms may be present, but 



426 Fevers and Miasmatic Diseases. 

are often absent or pass unnoticed. They are peevishness or apathy, 
distaste for food, languor, and sometimes headache in older children. 
The onset is often quite sudden. 

In the initial stages, rigor is very rare, even in septicaemia, acute 
necrosis, and ague. It is generally absent in the eruptive fevers and 
pneumonia; older children complain of chilliness. Dusky pallor of 
the face and lips, and cold extremities and burning heat of the body, 
are not uncommon at the outset of a sharp attack of fever. In dis- 
cussing the cause of convulsions in children, Hughlings Jackson, M. D., 
makes the following reference to that now under consideration : " Con- 
vulsions, which may occur as an initial symptom, may occur in almost 
any acute febrile disease, but are, on the whole, more common in the 
eruptive fevers; it does not materially affect the ultimate prognosis." 
We must not lose sight of the fact that children are liable to convul- 
sions under many different circumstances, such as rickets, a state of 
exhaustion, dentition, diarrhoea, and organic disease of the brain, 
besides the convulsive seizures termed essential. All these possible 
causes have to be reckoned with when we are called upon to pronounce 
an opinion on a case of convulsion. If the temperature is high dur- 
ing the convulsion, and continues to rise as the seizure passes off, we 
may suspect the outset of some acute fever. An inquiry into the fam- 
ily or personal history will often thrown light on the cause. A clue 
may be found in examining the chest. Albuminuria immediately fol- 
lowing a convulsion is of some diagnostic value at the outset of a fever ; 
it may be due to the direct effects of the convulsions. The question 
may arise whether a convulsion indicates the outset of acute cerebral 
disease, especially tubercular meningitis. This is only likely to occur 
where convulsion is the first symptom for which we are consulted. 
Tubercular meningitis is a disease of gradual and insidious outset, and 
very rarely begins with convulsions. The status epilepticus must be 
carefully distinguished from tubercular meningitis. In this condi- 
tion, which results from a quick succession of fits, the temperature 
sometimes attains a considerable height, 106 degrees Fahrenheit, and 
the urine may be albuminous. Of far more serious import are con- 
vulsions occurring during the eruptive stage of scarlet fever, measles, 
and variola. In the later stages of fever, when the patient is much 
exhausted, there is again manifested a tendency to convulsions, which 
occasionally usher in the fatal event. Vomiting is a very frequent 
early symptom. It may take place after a meal or without relation to 
the ingestion of food; when severe and repeated, it is apt to induce 
collapse. The association of repeated vomiting with headache and 
drowsiness will raise suspicion of meningeal trouble. This grouping 
of symptoms, however, is sometimes seen in simple continued fever, 
and has been known to precede the crisis of acute pneumonia. The 
skin is usually dry and hot at times, especially in tubercular disease. 
Sweating is decidedly rarer in children than in adults; the perspira- 
tion of acute rheumatism is often limited to the palms and soles, that 



Fevers and Miasmatic Diseases. 427 

of rickets to the head. Pyaemia may run its course without a sweat. 
Except at the crisis of a fever, the occurrence of profuse sweat is an 
unfavorable symptom. Sweats are apt to occur in chronic tubercular 
disease with suppuration, and in the later stages of tubercular affec- 
tions of the chest and abdomen. As a rule, however, phthisical patients 
do not sweat in excess. Occasionally there is an eruption of sudamina 
on the chest, which may lead to a branny desquamation. In these 
cases bed-sores seldom occur. 

The aspect of the skin is very variable. Some children are pale 
at the onset of fever ; others look hot and flushed. The two conditions 
may alternate in the same patient. When the skin is usually flushed, 
the condition is sometimes designated as the "febrile blush.'' In some 
cases it presents a close, though superficial, resemblance to the rash of 
scarlet fever, and has more than once led to a mistaken diagnosis, 
even at the hands of competent observers. Cases are reported as being 
admitted each year into fever hospitals as scarlatina, which ultimately 
prove to be cases of simple continued fever, or they have developed 
into typhoid. The febrile blush is generally an early phenomenon. 
Its duration is very variable, lasting in some cases but an hour or 
two; in others it persists, with varying intensity, for several days. 
Sometimes it is followed by branny desquamation. A high tempera- 
ture is by no means necessary to its occurrence. The febrile blush is 
usually well developed on the face, neck, and upper part of the chest. 
It also affects the dependent parts of the body, the back, the buttocks, 
and backs of the arms and legs. It is usually faint on the lower 
abdomen and inner aspect of the thighs. When fully developed, it 
consists of a bright reddish-pink blush, uniformly diffused beneath the 
surface, and fading momentarily on pressure. It is very evanescent, 
and apt to shift from place to place. Exposure of the chest often 
causes it to disappear entirely in a few minutes, to return again as 
soon as the clothing is replaced. In some cases it occurs in large, irreg- 
ular patches with ill-defined borders. The distinction from the rash 
of scarlet fever is not likely to offer any difficulties, except in cases 
where the blush is unusually intense and persistent. The chief points 
of difference are the following : On the face the febrile blush is often 
well marked, and reaches to the margin of the lips ; the rash of scarlet 
fever is generally faint on the face, and leaves untouched a zone of 
skin around the mouth. The blush of fever is usually faint or absent 
in the groin and on the inner aspect of the thighs, parts where the scar- 
latina eruption is generally well marked. The blush lies beneath the 
surface of a perfectly smooth skin ; the rash of scarlet fever is puncti- 
form, and not necessarily uniformly diffused. The blush is less per- 
sistent than the rash, and more susceptible to external influences. 

Labial herpes is seen in many kinds of fever, but is not neces- 
sarily an early sign. It is relatively common in pneumonia, not rare 
in acute tonsillitis, febrile-gastric disorders, and febricula, and may 
occur in the eruptive fevers. Its presence practically excludes the 



428 Fevers and Miasmatic Diseases. 

diagnosis of typhoid fever. The lips dry quickly and become cracked. 
Children are apt to pick and canse them to bleed, and sometimes to 
become swollen. This picking at the lips or at other parts of the body 
is often a sign of nervous prostration. 

The tongue does not present with any constancy, or in the same 
degree, the varieties of aspect which characterize it in certain febrile 
diseases of adults, and is therefore of little value in helping the diag- 
nosis. An exception may be made in favor of scarlet fever. Slight 
furring on the dorsum with redness of the tip and edges is the rule, 
but the tongue may remain clean and dry throughout. A dry tongue 
may become brown, but it rarely cracks to any great extent, even in 
typhoid fever. The thick creamy fur of rheumatic fever is hardly 
ever seen. Some injection of the fauces is common at the onset of an 
acute fever. The appearance presented differs in degree only from a 
mild scarlatinal throat. 

The digestive functions are almost invariably impaired. The 
salivary and pancreatic secretions are much diminished, giving- rise to 
dryness of mouth, great thirst, distaste for food, and great difficulty in 
assimilating starchy food. The secretion of bile is probably also les- 
sened; the stools are often pale and offensive. There is usually con- 
stipation, but this is a rule to which there are many exceptions. 
Diarrhea is rare at the onset of fever, but may accompany the crisis. 

The pulse of children in fever does not exhibit any marked pecul- 
iarities. In infants undue pulsation of the fontanels will suggest 
excited vascular action. The frequency of the pulse is always 
increased. It is often full and bounding in the earlier stages, but 
tends to become smaller and weaker as exhaustion increases, and in the 
later stages, when death is threatening, is often running or thready, 
and impossible to count. 

Increase in the frequency of the respiratory act is a constant and 
important concomitant of fever. The respirations may rise to forty 
per minute, and the alsenasi be set in action, even in the absence of any 
pulmonary complication. Rhonchi and scattered rales may also be 
heard over the lung during the exacerbations of a simple catarrhal 
fever, which disappear entirely when the temperature remits. This 
accession of pulmonary signs is occasionally very well marked during 
the hot stage of ague, and may render the diagnosis from pneumonia 
or broncho-pneumonia somewhat difficult. It is to be remembered, 
however, that while catarrhal fevers may be accompanied by very defi- 
nite pulmonary signs, the simple bronchitis of children is often attended 
by high temperature, even though no pneumonia is present. The dis- 
turbances of the sensorium vary greatly in different cases. The rea- 
son of this is to be sought partly in the individual differences of tem- 
perament and resisting powers, partly in the nature and degree of the 
intoxication. Many a case of simple fever runs its course without 
causing any appreciable impairment of health. In others cerebral 
symptoms, vomiting, drowsiness, headache, etc., predominate to such 



Fevers and Miasmatic Diseases. 429 

an extent as to justify the recognition of a cerebral type of simple 
fever. Profound and rapid prostration, with or without coma or con- 
vulsions, is often seen in the malignant forms of the fever-poisoning of 
the nervous system. Restlessness, irritability, and drowsiness are com- 
mon symptoms. Uneasy sleep and sleeplessness are also of frequent 
occurrence; and although in themselves insignificant symptoms, they 
demand close attention and proper treatment. A few hours of peace- 
ful sleep will do more than anything else to restore the strength of a 
child ill with fever. Children under five do not generally complain 
of headache. Altogether, this symptom is far less common than in 
adults. It is not rare, however, in the early stages of typhoid fever, 
and may occur in simple continued fever. The occasional occurrence 
of nausea during the course of a fever has no special significance. 
Severe and repeated vomiting, on the other hand, is a grave symptom, 
requiring prompt treatment, and liable to do much harm by increasing 
prostration. Delirium is relatively uncommon in children, and the 
key-note to this peculiarity probably lies in the incomplete state of their 
mental evolution. Talking during sleep, however, is common enough, 
and a tendency to ramble in their talk, when awake, is not rare. If 
prostration is very great, stupor, subsultus tendimum, tendency to 
convulsion, and picking of the body or the bedclothes are all unfavor- 
able symptoms. 

Hyperpyrexia is rare, except as the immediate precursor of death, 
when it may be regarded as one of the earliest stages in the process of 
dying. This form is not amenable to treatment. Rheumatic hyper- 
pyrexia is said to be very rare. 

The changes in the urine do not call for any lengthy notice. The 
total quantity is reduced and the specific gravity raised. On cooling, 
the urine generally deposits a sediment of white or yellowish-white 
lithates. This amorphous precipitate of mixed urates dissolves readily 
on heating. During convalescence it is common to find a cloud of 
white phosphates precipitated by heat, which dissolve at once on the 
addition of a drop of acetic acid. At this period the urine may also 
contain uric acid and oxalate of lime crystals. 

The occurrence of temporary albuminaris is by no means rare. 
The quantity of albumen present is always small, rarely exceeding a 
large trace, and disappears rapidly with convalescence. The effect of 
fever on the body is generally well marked in children. Wasting is 
general, muscles and cellular tissues chiefly, but probably all tissues in 
varying degree. Emaciation often takes place with startling rapidity. 
A fever of twenty-four hours' duration may make a noticeable change, 
especially in plump, fat children. 

Treatment. — In dealing with fever two lines of treatment are 
open to us. The first is to remove or destroy the fever poison. The 
other — our only resource in cases where the poison is out of reach- 
is to place our patient under the most favorable conditions, and treat 
injurious symptoms and complications as they arise. The child should 



430 Fevers and Miasmatic Diseases. 

be placed in an airy, well-ventilated room with an equable temperature, 
between 60 degrees and 65 degrees Fahrenheit. The clothing and bed- 
covering should be light but adequate, our object being to allow radia- 
tion and evaporation free play without exposing the patient to the 
variations of the external temperature, which are apt to produce slight 
shivers. Linen clothing is to be preferred to flannel during the active 
stages of fever, except when there is much sweating. It is more pleas- 
ant to wear, is not so apt to irritate the skin, and can be more easily 
and effectually cleaned. Where linen is not used in families, muslin 
may be used. During convalescence, a flannel vest may be worn with 
advantage. Soiled body and bed linen should always be immediately 
changed and removed from a sick-room. 

The diet should be bland and mostly liquid, and the food is best 
given in small quantities at short intervals. During fever the 
processes of digestion are always much impaired, and we should be 
careful to avoid overloading the stomach in our anxiety to sustain the 
strength of the patient. Milk is to be given as a food, and not as a 
drink. Cold water in plenty, or barley water flavored with lemon, may 
be taken to quench thirst. If pure milk is not easily digested it may 
be diluted with plain barley water or with a solution of gelatine or gum 
acacia. Beef tea and mutton broth are generally well borne, and should 
always form part of the diet of children over eighteen months old. If 
they should disagree, chicken broth or veal tea will be available. If 
the stomach becomes intolerant, pancreatized milk or beef tea may be 
tried by the mouth, or, if this should fail, may be given by the rectum 
in the form of nutrient enemas. 

Constipation should be relieved, preferably by means of enemas 
(soap and warm water, or glycerine and water). 

Diuretics and diaphoretic salines may be given, with plenty of 
water. They tend to promote free action of the skin and kidneys, and 
facilitate the removal from the tissues of waste products of fever. 

Fevers due to some disorder of digestion generally yield at once 
to a purge or an emetic ; and as many of the simple fevers of children 
are of this nature, castor-oil and calomel have acquired great repute 
in their treatment. The pyrexia which accompanies certain specific- 
diseases will often yield to drugs which exert a specific action on the 
disease. As examples may be mentioned quinine and salicylates in 
the treatment of malaria and acute rheumatism. Fevers depending 
on purely local causes, in accessible situations, are also readily amen- 
able to suitable treatment. Such are the putrid fevers of foul wounds, 
of acute abscesses, ulcerative stomatitis, and others. These classes of 
fever represent but a small fraction of the whole number, and do not 
include those which are most often dangerous to life. 

When the cause of fever is beyond our reach, we must treat symp- 
toms. Of these, pyrexia is notably one of the most important, and 
also the one that we are best able to cope with. It is well to bear in 
mind, however, that children are in general very susceptible to the 



Fevers and Miasmatic Diseases. 431 

action of antipyretics, and that unless due care is exercised in the 
selection of suitable cases and appropriate methods, this form of treat- 
ment will often disappoint expectations. The occurrence of collapse 
constitutes one of the chief risks in the employment of antipyretics. 
To guard against this danger, they should always be used tentatively 
at the outset, and their effect carefully watched. Thus, after a bath 
or a dose of antifebrin, the temperature should be taken at least twice 
within an hour, in the mouth or in the rectum, according to the age 
of the patient. Any symptoms of collapse should at once be met by 
the exhibition of stimulants and warm applications to its surface. 
When cold applications cause much distress to the patient, they are of 
doubtful benefit, and should be discontinued, unless the reduction of 
the temperature is imperative, as in hyperpyrexia. In certain states 
external application of cold is contraindicated. In such a case cold is 
likely to aggravate the cyanosis and further depress the patient, whereas 
a warm bath and a little alcohol will often quickly improve the general 
condition. In some cases of cerebral disease where the employment of 
ice-bags or cold-water coils to the head has been a source of discomfort 
and irritation, much benefit has attended the substitution of hot 
fomentations. 

Although it is said by the best authorities to be impossible to lay 
down hard and fast rules for their use, antipyretics may legitimately 
be employed, (1) in cases of sustained high temperature above 105 
degrees Fahrenheit; (2) in all cases of hyperpyrexia; and (3) when- 
ever the rise of temperature is accompanied by aggravation of the other 
symptoms, such as restlessness, want of sleep, drowsiness, delirium, or 
rapidity and weakness of cardiac action. These indications are more 
than ever imperative when the patient's strength has already been 
taxed by prolonged fever, and in children of weak physique. The 
means at our disposal are, (1) drugs, and (2) external application of 
cold. 

The drugs on which most reliance can be placed (as agreed upon 
by all authors) are quinine in full doses, salicylates, and the class of 
antipyretics now in vogue, viz., antipyrine, antifebrine, and phena- 
cetine. The last-named drugs must be given with due caution. In fnlJ 
doses they may depress the heart to an alarming degree; and this 
constitutes a serious objection to their use when there is much pros- 
tration. 

Antipyrine has been extensively used, and its mode of action 
"increases skin radiation, lessens heat production, diminishes nitrog- 
enous waste by checking destructive metabolism, and frequently, but 
not always, increases perspiration, while it generally slows the heart 
and slightly increases the tension of the radial pulse. It may fairly 
claim, therefore, to be a true antipyretic, and not merely a refrigerant." 
It has met with marked success in the treatment of fever. Its effect on 
the temperature is, unfortunately, very transitory, so that it may be 
necessary to repeat the dose every hour and a half to keep the pyrexia 



432 Fevers and Miasmatic Diseases. 

under control. At times it causes gastric irritation and troublesome 
vomiting and occasionally diarrhea. This tendency may be obviated 
to some extent by adding one or two drops of tincture of opium ; and it 
is a good plan to give a little whisky at the time to prevent depression. 
The administration of antipyrine is sometimes followed by an eruption 
of a measle-like appearance, a papular erythema, which appears first 
on the arms and dependent parts, and may spread to the remainder 
of the body. This rash is of no serious import, and quickly disappears 
on discontinuing the drug. 

Antifebrine (acetanilid) possesses several advantages over anti- 
pyrine, and is gradually superseding it in the treatment of fever. Its 
mode of action is probably the same. As an antipyretic it is more 
rapid and powerful in its action, and its effect on the temperature is 
rather more permanent. Serious collapse is liable to occur when it is 
given incautiously, and it may cause rigors. It does not produce rash, 
and rarely creates nausea. It should be given tentatively at first, one- 
fourth to one-half grain to a child two years old, and the dose may be 
gradually increased to one and one-half grains for a child five years 
old. The dose required will vary according to the stage and nature of 
the fever. Full doses are generally needed in the early stages of the 
fever, specially in scarlet fever, in which the drug has proved of con- 
siderable value. The pyrexia of typhoid fever, as a rule, yields readily 
to all antipyretics. 

Phenacetine, so far as we know, acts in the same manner as anti- 
febrine, and is said to possess the same advantage. 

Aconite is an old-time remedy, and is of conspicuous value in 
catarrhal fever the result of chill, and in acute tonsillitis. If given 
in the earliest stages, the general malaise, sense of chilliness or burn- 
ing heat, pains, etc., rapidly disappear, and give place to a feeling of 
comfort. The author prefers small doses of aconite, from one-fourth 
to one-drop doses for children ranging from six months old to five years 
of age ; it may be given, according to age, every half hour to every hour 
in cases of catarrhal fever or malarial fever. The skin soon becomes 
moist, and may sweat profusely, and the pulse is lowered in frequency. 
Much care is required in its administration. Owing to its powerful 
depressent action on the heart, its use must be discontinued when the 
fever has abated. Quinine must be given every three hours in small 
doses (two grains) in all cases of malaria, till there is no more fever. 
In all cases of fever, at the onset small doses of calomel, with one-half 
grain of soda for a child from six months old up to puberty, one-tenth 
of a grain to the infant six months of age, may be given every hour till 
three or four doses have been administered ; and in about eight hours 
after the last dose has been administered, one may give a dose of the 
syrup of rhubarb (if castor-oil can be taken without too much nausea, it 
is preferable) to move off the calomel. Older children may take one- 
fourth of a grain of calomel with a grain of soda and a little sugar 
given every hour until three doses have been given; then follow, as 



Fevers and Miasmatic Diseases. 438 

above advised, with a laxative. Keep up the use of quinine, as pre- 
scribed, until the child misses the daily paroxysm of fever. After 
the fever has broken, a tonic of iron, quinine, and a little strychnse 
(Wyeth's Elixir) may be given according to age for two or three weeks. 

The action of cold is not exactly known ; it is highly probable that 
its good effects are attributable to some stimulant action on the system, 
as well as to the abstraction of heat from the surface and the probable 
diminution of heat production. It is certain that this mode of treat- 
ment is far more effective in rousing the depressed sensorium and com- 
bating prostration than the antipyretic drugs. As a rule it induces a 
refreshing sleep, whereas this desirable result only occasionally follows 
the administration of antipyrine and its allied remedies. This mode 
of treatment is always to be preferred when there is much prostration. 
In a general way children do not stand cold very well, and tepid appli- 
cations should always be given a child first, before using cold. 

Sponging. — The face, trunk, and limbs are sponged over for ten 
or fifteen minutes with tepid water (80 degrees Fahrenheit) or with 
cold water (50 degrees Fahrenheit or lower). The surface is then rap- 
idly dried and the covering replaced. A sheet and a single blanket will 
generally suffice. If tepid water does not bring about the desired effect, 
a graduated bath is likely to answer better than sponging with cold water. 

Compress. — This consists in the application to the body or limbs of 
cloths wrung out of cold or ice-water, according to the temperature. If 
the temperature is 103 degrees to 105 degrees Fahrenheit, cold water 
or ice-water may be used. The cloths require to be very frequently 
changed, and should be discontinued when the temperature has fallen 
below or to 100 degrees Fahrenheit. Like sponging, compresses 
demand constant attention on the part of the nurse, and may interfere 
with sleep. They are chiefly used in typhoid fever when there is much 
abdominal distention and it is not advisable to disturb the patient. 

Bathing. — The bath is the most powerful antipyretic agent we 
possess, and almost the only one that has achieved success in the treat- 
ment of hyperpyrexia. (William Pasteur, M. D., F. R. C. P.) Its 
chief value in the treatment of children, however, is due to its com- 
bined stimulating and sedative effect on the nervous system. To allay 
restlessness and general malaise, a warm bath (95 degrees Fahrenheit) 
will often accomplish all that is needed, and is usually followed by some 
lowering of the temperature. The effect of a bath at 80 degrees 
Fahrenheit is more powerful and lasting, but less agreeable to the 
patient. When reduction of temperature is the primary object, a 
graduated bath is, on the whole, the most convenient plan. The child 
is placed in a bath at 90 degrees Fahrenheit, which rapidly lowers in 
temperature by the addition of cold or ice-water. The bath should be 
of short duration, and given in the presence of a medical attendant. 
The rectum temperature should be taken at intervals of a few minutes, 
and the child removed from the bath when it has reached 100 degrees 
Fahrenheit, as the fall of temperature may now be considerable. It is 

28 



434 Fevers and Miasmatic Diseases. 

often advisable to give small doses of whisky both before and after the 
bath. In ordinary cases the occurrence of shivering, or of a blueness 
of the lips and extremities, is an indication of immediate removal from 
the bath ; and warmth must be applied over the heart and to the feet till 
the chilliness abates. 

Cold Wet Pack. — The patient is wrapped in a sheet wrung out of 
cold or ice-water, and covered over with a thick blanket. The pack 
should not be continued longer than from ten to fifteen minutes. 

The water-bed or water-pillow may be used to reduce the tempera- 
ture by allowing water at a suitable temperature to circulate through it ; 
but it is a convenient and satisfactory method of carrying out this 
object. 

Ice-bags or ice-water coils are applied to the head for the pur- 
pose of allaying meningeal inflammation and reducing temperature. 
A piece of flannel should be laid between the ice-bag and the head, or 
wrapped around the ice-bag if only one thickness of flannel is needed. 

In combating prostration and the exhaustion of prolonged fever, 
stimulants must be used, and are a most powerful means of supporting 
the vital powers till the exhaustion is overcome. Besides the general 
condition and aspect of the patient, the state of the tongue and that of 
the pulse afford the safest indications for their employment. When 
stimulants can not be given by the mouth, alcohol or ether may be 
administered by subcutaneous injection, or in the form of enema with 
a sufficiency of water or beef tea. 



CHAPTEE XXVI. 
SIMPLE CONTINUED FEVER. 

Definition. — This is a fever of short duration, which is not char- 
acterized by the presence of any definite local lesion, or preceded by 
any definite local lesion, or by any known invariable antecedent. It is, 
in truth, a morbid genus without essential attributes, and made up, in 
large part, of aberrant varieties of other species. An initial diagnosis 
of febricula has often to be set aside in favor of pneumonia, typhoid, 
tonsillitis, or some other acute febrile disease ; and the converse hap- 
pens with equal frequency. Such facts bear strong testimony to the 
indeterminate character of this affection. (Pasteur.) 

Simple fevers are very common in childhood, and their early 
recognition is of great practical value. They may be roughly grouped 
under the following heads: — 

1. Abortive or incomplete forms of the specific continued fevers, 
typhus, typhoid, and relapsing fever. Cases of irregular types may 
occur at any time, but are more frequent during the epidemic prevalence 
of these diseases. 

2. Cases of scarlet fever, modified variola, and more rarely measles 
and erysipelas, in which the eruption is either absent or unnoticed. 

3. In rare instances, anomalous forms of intermittent fever. 

4. Fevers due to the effects of some localized inflammation, in 
which the local signs are transient, ill developed, or beyond the reach 
of observation. Cases of this kind occur in connection with lymph- 
adenitis, tonsillitis, and acute catarrhal affections of the alimentary and 
respiratory mucous membranes. 

5. The whole group of fevers caused by disorders of digestion, 
attended by the absorption of pyrogenic substances. 

6. Fevers depending on some disturbance or exhaustion of the 
nervous system, as a consequence of exposure to heat or of some 
peripheral nerve irritation. 

The only symptom, so it is said, common to the whole class is 
fever or pyrexia, and in a considerable number of the cases it consti- 
tutes the whole disease. The access is generally sudden, but may be 
gradual. The temperature often attains a considerable height, 104 
degrees to 105 degrees Fahrenheit. The initial rise may be ushered in 
by any one of the symptoms considered in an earlier part of this article. 
Vomiting is common ; convulsions, on the whole, are rare. Some or all 
of the clinical symptoms of fever, before described, may be present in 
varying degree. The febrile blush is often particularly well marked. 

(435) 



436 Simple Continued Fever. 

The pulse and respirations are always increased in frequency. Rest- 
lessness, wakefulness, and slight delirium are not infrequent. Consti- 
pation is the rule, with furred tongue and disinclination for food. 
Thirst is nearly always excessive. The urine is usually scanty, being 
thickly coated ; vomiting frequent, thirst unquenchable, and the bowels 
difficult to move. 

In others the respiratory organs bear the brunt of the attack; the 
breathing is quick and somewhat labored, the alasnasi acting strongly, 
the face a little dusky, while numerous rales and rhonchi are audible 
all over the chest; meanwhile the tongue may remain almost clean, 
and digestion be but little impaired. A cerebral type has already been 
referred to, in which headache, repeated vomiting, intolerance of light, 
and irritability or tendency to delirium, are prominent symptoms. 

The temperature generally falls by crisis at the end of two or 
three or five or six days, and convalescence is always rapid. The diag- 
nosis rests chiefly on the exclusion of other acute fevers. 

Typhoid fever, pneumonia, tonsillitis, scarlet fever, and menin- 
gitis are the diseases of which the diagnosis is most difficult in the early 
stages. The occurrence of sharp attacks of fever in a perfectly healthy 
child, is in favor of f ebricula. The prognosis is always favorable ; 
in the way of treatment, rest in bed for a day or two, with liquid diet, 
is all that is said to be required in some cases. The writer would advise, 
at the onset of febrile diseases, such remedies as are necessary to act 
directly on the liver. Very small doses of calomel, with a saline, as 
Rochelle salts or citrate of magnesia, will always relieve the portal cir- 
culation; this, with plenty of liquid food, milk, eggs (soft-boiled), beef 
tea, etc., with quiet and hygienic surroundings, will probably be all 
that is necessary in some febrile cases. Cool drinks and diaphoretic 
salines are very useful throughout the entire stages of the fever. It 
must be borne in mind that what appears to be simple fever at the out- 
set may prove to be some severe or highly infectious disease; and, 
further, it would seem that certain forms of f ebricula are infectious. 
It is common experience to find all the children in a household sicken 
one after another with a fever of short duration, accompanied, some- 
times by bronchial catarrh, and at other times by marked gastric dis- 
turbance. A knowledge of these facts should be borne in mind, thus 
making us doubly cautious in dealing with cases of this nature. 



CHAPTEE XXYII. 



THEEMIC EEVEE; HEAT STEOKE; I^SULATIOJST. 

Definition. — Acute fever produced by exposure to heat. Thermic 
fever is always dependent upon exposure to heat, natural or unnatural. 
Owing to interference with evaporation, a hot, moist atmosphere is 
much more dangerous than dry heat; hence sunstroke is rare in a dry 
climate, and frequent in tropical lowlands, as well as in sugar refineries, 
laundries, and similar places. It may occur in the night as well as in 
the day. Very powerful as predisposing causes are lack of acclimatiza- 
tion, excessive bodily fatigue, and intemperance. Males are more fre- 
quently affected than females, because of their more frequent exposure. 

Symptoms. — The symptoms of sunstroke are a combined fever 
without local disease, with a- tendency to weakness and the typhoid 
state, and various disturbances of function. In India, it is stated, the 
disease is apt to end in a sudden development of the severest type of 
thermic fever and death; in America the patients usually recover under 
treatment. 

Sunstroke commonly begins with abrupt complete unconscious- 
ness, although prodromes, such as general distress, a great burning 
heat, and chromopapsia, or colored vision, do occur. With the uncon- 
sciousness there is usually muttering delirium, great muscular rest- 
lessness, partial convulsions, or violent epileptiform attacks ; sometimes 
there is quiet coma, with relaxation. The pulse may be bounding and 
full, but is almost invariably compressible, and if not originally rapid 
and feeble, becomes so as the case progresses ; vomiting and purging 
are common. 

The whole body is apt to exude a peculiar odor, which is especially 
strong in the faecal discharges. The characteristic symptom is a tem- 
perature which is rarely below 108 degrees Fahrenheit, and may reach 
113 degrees Fahrenheit; the urine is scanty, sometimes albuminous, 
not rarely suppressed. The breathing is more or less labored and irreg- 
ular. The pupils are dilated. In most cases some response can be 
obtained by shaking the patient, except very late in the disorder. Death 
may occur in about half an hour, but usually is postponed for a longer 
period : it is ordinarily the result of a slow, simultaneous failure of 
respiration and of heart action, that may be due to asphyxia, or iu very 
acute cases to cardiac arrest. 

A condition similar to sunstroke may develop in so-called cerebral 
rheumatism and other affections with very high temperature. As was 

(437) 



438 Thermic Fever; Heat Stroke; Insulation. 

first painted out by Dr. Comegys, many of the cases of so-called cholera 
infantum occurring in young children in the large cities of America 
during the summer months, are really forms of thermic fever. The 
symptoms in such cases are high fever, intense thirst, rapid pulse, and 
respiration, vomiting, purging; there are more or less pronounced evi- 
dences of cerebral disturbance, such as insomnia, headache, contracted 
pupils, delirium, and finally coma, ending in death. (Fitz, M. D.) 

Diagnosis. — The diagnosis is made the moment the temperature 
is found to be 108 degrees Fahrenheit, or upward, because such tem- 
perature produces a thermic fever whether the temperature is due to 
external heat or not. A knowledge of the exposure to heat and high 
temperature confirms the diagnosis. 

Treatment. — Mild cases of thermic fever are most satisfactorily 
treated with cold or graduated baths. In severe cases with unequivocal 
hyperpyrexia, immediate treatment is of paramount importance. Cold 
affusion, cold baths, and rubbing the surface with ice, are the most 
powerful means at our command. The thermometer in the mouth 
or rectum is our only safe guide as to the effect of treatment. Great 
care must be used to avoid collapse. When exposure to high tempera- 
ture can not be helped, it is essential that the bodily health be main- 
tained, and that all excesses in labor or in pleasure be avoided. The 
diet should be largely farinaceous, and the emunctories should be kept 
active by eating fruit, and by the free use of cold water and of lemon- 
ade, and of mild salines if necessary. Ice-water, if taken in large 
quantities, may do harm by suddenly chilling the stomach, and drunk 
at meals may interfere with digestion; but drunk in moderate quanti- 
ties at short intervals between meals, it does great good by reducing 
the general temperature and aiding free perspiration. All alcoholic 
drinks are to be avoided, except that a little claret or red wine may be 
added to the ice-water with advantage to make it more agreeable to the 
gastro-intestinal tract and more active in promoting perspiration. Cold 
baths should be used frequently, especially if at any time the bodily 
temperature be found to be rising. According to Guiteras, in sub- 
acute or continued thermic fever the best plan is to wrap the patient 
in a dry sheet, lift him into a tub of water at a temperature of 80 
degrees Fahrenheit, and then rapidly cool the water with ice, the immer- 
sion continuing from forty-five to fifty-five minutes, according to the 
effect upon the mouth temperature. 

The patient is then to be placed upon a blanket, the skin partially 
dried, and the body covered. Guiteras states that it is very important 
to avoid currents of air blowing upon the patient, and the bath must 
be given in a small, warm room ; also that in most cases great advantage 
is to be obtained by giving moderate doses of whisky, with from twenty 
to thirty minims of tincture of digitalis about twenty minutes after the 
bath. Guiteras never found it necessary to give more than two baths 
in the twenty-four hours, but in some cases the baths had to be used 
for many days. 



Thermic Fever 4 Heat Stroke; Insulation. 439 

In acute thermic fever the bodily temperature is to be reduced at 
once by the means most convenient. There should be no waiting for 
the calling of a physician. The patient should be carried to the shade, 
and have cold affusions over the face and body, or should at once be 
put under a pump and be pumped on, or should be put into a bath of 
ice-water. In giving the cold bath a thermometer should be put in 
the mouth or rectum. Remove the patient from the bath when tem- 
perature reaches 101 degrees Fahrenheit, as it is not rare for the tem- 
perature to continue to fall after removal from the bath. Alcohol, and 
strychnine and digitalis, administered hypodermically, may be neces- 
sary even while the patient is in the bath, when the symptoms seem to 
point urgently to them ; antipyrine is said to be a valuable remedy for 
the purpose of preventing rise of temperature after the patient has 
been taken out of the bath. 

It is said that when there is a hard pulse in a case of sunstroke, 
and the symptoms are essentially those of a congestive apoplexy, free 
venesection is sometimes useful, as it is especially a powerful reducer 
of bodily temperature. When the convulsive, tendency is very acute, 
morphine may be given hypodermically. 

As soon as possible after sunstroke, the patient should be moved 
to a cool atmosphere, and should be kept upon a light, farinaceous 
diet, and generally treated as if in danger of an acute meningo- 
encephalitis. Especially if there is any tendency to headache or 
cerebral flushings, local blood-letting, followed by blisters and other 
forms of counter-irritation, should be used. If the headache is intense 
when the patient comes to himself, general venesection, it is said, may 
afford a means of relief. 

SEQUELAE. 

In adults, cerebral distress or pain, with failure of general 
vigor, dyspeptic symptoms, and various indications of disturbed innerva- 
tion, frequently occur after thermic fever. In pronounced cases 
the pain in the head is more or less constant, but subject to exacerba- 
tions, and is sometimes associated with pain and stiffness in the back 
of the neck. With it there may be vertigo, decided failure of mem- 
ory, and of the power of fixing the attention, insomnia, and excessive 
nervousness and irritability. When such is the case there is usually 
a marked lowering of the general health, with loss of strength, and 
the peculiar invalid look which characterizes some chronic diseases. 
The one symptom which is always present, and which is diagnostic 
in these cases, is the inability to withstand heat ; not only are the 
symptoms greatly exaggerated, it may be to the point of severe ill- 
ness during the summer months, but in most cases headache and great 
distress are produced by going into a hot room even in winter. 

The treatment is, first, absolute avoidance of any exposure to 
even moderate heat, combined with intellectual and physical rest ; sec- 



440 Thermic Fever; Heat Stroke; Insulation. 

ond, the treatment, counter-irritation, fly-blister, actual thermo-cautery, 
combined with the internal administration of mercurials, and potas- 
sium iodide in very small continuous doses (one-fifth grain of cor- 
rosive sublimate, one to two grains of iodide, three times a day) ; 
third, restriction to a largely farinaceous, non-irritating diet, and care- 
ful attention to all minor symptoms as they arise. (Eitz, M. D.) 



CHAPTEK XXVIII. 
ENTERIC OR TYPHOID FEVER. 

Definition. — This is an acute infectious disease due to a specific 
cause. It is characterized by gastro-intestinal catarrh, febrile move- 
ment of continued type, varying in duration from ten to twenty days, 
and even longer, marked prostration, rapid wasting, mild nervous 
symptoms, and a scanty eruption of isolated, slightly elevated, rose- 
colored spots, disappearing on pressure and developed in successive 
crops. Enteric fever in infancy and childhood does not conform 
closely to the type of the affection in adult life. 

Symptoms. — Infantile remittent fever; nervous fever; infantile 
hectic fever; gastric fever; acute mesenteric fever; entero-mesenteric 
fever; intestinal fever; pathogenic fever; typhus abdominalis fever; 
ileo-typhus fever. 

The names by which this fever has been described at various 
periods and by different authors are derived from its supposed rela- 
tionship to typhus, its mode of prevalence, its remittent character, its 
long duration, its supposed nervous origin, the occurrence of septic 
or putrid symptoms, its hectic phenomena, the presence of symptoms 
denoting disturbances of the stomach and liver, the intestinal symp- 
toms, the morbid anatomy, and its mode of origin. 

We do not consider it necessary, however, to enumerate all these 
names, as many of them have fallen out of use. 

Etiology. — Enteric or typhoid is due to the entrance into a sus- 
ceptible organism of a specific infecting principle. The etiological 
consideration relating to enteric fever is equally applicable to child- 
hood and to adult life. 

Predisposing Influences. — These are all conditions which favor 
the development and accumulation of the infecting principle, and 
those conditions which increase the susceptibility of the individual 
to the cause of this particular fever and the liability of exposure to it. 

The geographic distribution of enteric fever is wide. In Amer- 
ica it prevails as the common fever from Hudson Bay to the Gulf 
of Mexico. In new and sparsely-settled districts, where the land is 
being gradually brought under cultivation, the malarial fevers occur; 
after a time, as population increases, the malarial disease and enteric 
fever will prevail side by side; finally, when the land has been gen- 
erally taken up and drained, and tilled for some generations, and vil- 
lages and cities abound, the malarial diseases, true ague and remit- 
tents, impress communities but faintly, or disappear altogether, while 

(441) 



442 Enteric or Typhoid Fever. 

enteric fever becomes common, and asserts itself as the predomi- 
nant endemic fever in proportion to the neglect of the sanitary meas- 
ures by which alone it can be kept in check in populous localities. 

Climate, not of itself, but indirectly or as determining the mode 
of life in communities, has a manifest influence upon the extent of 
the prevalence of enteric fever. Neither is it by any means confined 
to temperate climates; it is not uncommon in tropical and subtropical 
countries. 

The season of the year is a predisposing cause of great importance. 

Hirsch found that 519 epidemics of typhoid were distributed 
among the seasons as follows : In the spring, 29 ; in the summer, 132 ; 
in the autumn, 168 ; in the winter, 140. The number of cases in 
localities where the disease is endemic is usually greatest from August 
to November, decreasing in December, and is lowest from February 
to May, and again increasing in June. In some districts of the 
United States the popular name is "autumnal" or "fall fever." 

The state of the weather as regards dryness and moisture exerts 
a remarkable influence upon the prevalence of enteric fever. Hot and 
dry summers favor the development of the disease ; cold, wet summers 
check it. This statement is supported by the current testimony of 
observers in all countries. Dryness of the atmosphere alone does 
not, however, lead to an increase of enteric fever. In cities and other 
localities possessed of a system of underground drainage, warm, damp 
weather often leads to an outbreak of the disease, while heavy rain- 
falls, by flushing the drains, remove the cause to which its origin 
and spread are chiefly due. On the other hand, outbreaks of enteric 
fever may be traced to the influence of abundant rains in washing 
the germs of the disease into the water used for drinking purposes, 
particularly where the water supply is derived in part from tilled and 
therefore manured fields. 

Age is of great importance among the predisposing causes of 
enteric fever. This affection is preeminently a disease of adolescence 
and early adult life. The period of greatest susceptibility lies between 
the ages of fifteen and thirty, and the liability diminishes progressively 
both above and below these limits. Cases in the first year of life are 
exceedingly rare; but from this period (after the first year of life) 
through infancy and childhood, the liability is fully established. It 
is said that enteric fever is not common in advanced life, though well- 
authenticated cases in persons seventy and eighty years of age have 
been reported. Sex, in childhood, exerts no influence whatever as a 
predisposing cause. 

The mode of life is also without influence; enteric fever is as 
common in the houses of the rich as in the most crowded and desti- 
tute localities. 

Persons changing their residences from one part of the city to 
another, or from the country to the city, very frequently become sub- 
jects of the disease. 



Enteric or Typhoid Fever. 443 

The Exciting Causes. — It is regarded as settled that the cause 
of typhoid fever is a specific, organized, pathogenic germ. 

Numerous observers, Eberth, Klebs, Koch, and others, found 
bacilli in Peyer's patches, the mesenteric glands, and the spleen, from 
cases of this disease. Gaffky 1 found this organism in the mesenteric 
glands, liver, spleen, and kidneys, of twenty-six of a series of twenty- 
eight cases of enteric fever which he investigated. The subjects in 
which these bacteria were found had died in the earlier stages of the 
disease. Gaflky was unable to determine the presence of the typhoid 
bacilli in the blood or in the intestinal contents. 

This micro-organism, which is, then, the infecting principle of 
typhoid fever, is invariably derived from a previous case. It is said 
that there is no proof whatever that enteric fever can, in the absence 
of the specific, pathogenic germ of typhoid fever, be produced by the 
products of decay or decomposition, by tainted food, or by the 
action of other bacteria ; nor is there any reason to believe that typhoid 
bacilli can be developed from other micro-organisms. 

When introduced into the human body, this germ is capable, 
under favorable circumstances, of indefinitely reproducing itself. It 
is eliminated with the faecal discharges. It retains its activity, when 
it has found its way into favorable situations, for an indefinite period 
after it has passed out of the body, the requirements to this end being 
decomposing animal matter, especially faecal discharges and moisture. 
Therefore, cesspools, sewers, drains, dung-heaps, and wet, manured 
soils favor its prolonged existence. It is capable of indefinite multi- 
plication in these favorable situations. It remains suspended in, and 
may be conveyed by, water and milk. These fluids become the means 
of conveyance for the enteric-fever germ to the interior of the organism ; 
it is thought probable that it may also, under certain conditions, float 
in the atmosphere and thus occasionally find its way into the body 
by means of the inspired air. The germ retains its power of growth 
and reproduction within wide ranges of temperature. Prudden 2 
found it capable of growing after having been frozen in ice for one 
hundred and three days, and after having been heated to a tempera- 
ture of 132.8 degrees Fahrenheit. He also found that it retained its 
vitality after repeated alternate freezing and thawing. The investi- 
gations of Seitz, Wolfhugel, and others, show that it grows abundantly 
in milk. 

The fact that the infecting principle of enteric fever retains its 
vitality and is capable of multiplication in water of various tempera- 
tures has been fully established by the great number of carefully- 
studied outbreaks in the past. Among others, the well-known epi- 
demic of North Boston in 1843, described by Dr. Flint; the epidemic 
at Lausanne in the canton of Basel, Switzerland, and in 1872, and the 



l Mitth. A. D. Kaiseri. Gesund-Amt. Bd. 11, 1884. 
^Medical Record, IX, 1887. 



444 Enteric or Typhoid Fever. 

extensive outbreak of Plymouth, Pennsylvania, in 1885, have attracted 
special attention. 

The bacillus probably always infects the human individual through 
the intestinal tract. In the majority of cases it reaches it in the 
drinking water, although in numerous instances it has been carried by 
infected milk, and some very severe epidemics have been produced 
by eating oysters which have been planted near the discharging mouth 
of sewers. The researches of Chantemesse and Widal and Neuhaus 
seem to establish the fact that the microbe in question is able to pass 
by way of the placenta from the blood of the mother to that of the 
foetus. 

The period of incubation varies within wide limits; its precise 
determination in any given case is by no means so simple a matter 
as would at first sight appear. In an outbreak which occurred at Guild- 
ford, England, in 1867, the contaminated water which was the cause 
of the infection was supplied on a single day, the 17th of August. A 
large number of cases came under observation on the 3d and 4th of 
September, a period of incubation covering seventeen or eighteen days. 
On the other hand, there are facts tending to show that this period may 
be as short as two or four or eight days. 

The occurrence of house epidemics is to be explained by infec- 
tion at the same time or in quick succession of a number of individuals 
from the same source ; of cases developing in patients occupying beds 
adjacent to those of typhoid-fever cases in the wards of a hospital, 
by the conveyance of infecting/ material contained in the faecal dis- 
charges from one patient to another through the neglect or careless- 
ness of the attendants. 

Pathology and Morbid Anatomy. — The bacillus or spores, being 
swallowed, gain entrance to the organism by means of the intestines. 
This may be assumed to be the case, it is said, in those instances 
where the germs reach the organism by means of inspired air, as it is 
probable that they are engaged in the mucus of the mouth and then 
swallowed. If not destroyed in the stomach, the bacillus retains its 
vitality, passes on into the alkaline contents of the intestines, and here 
finds conditions favorable to its further development. In cases 
examined post mortem in the earliest stages of the disease, the lesions 
are mainly confined to the lymphatic tissues of the intestines. The 
bacillus penetrates into the solitary follicles, and there multiplies and 
forms colonies. From these colonies they migrate by way of the 
lymphatic vessels to the mesenteric ganglia, and by way of the radi- 
cels of the superior mesenteric vein to the liver, to be finally distrib- 
uted by the blood current to the spleen and other organs. 

A knowledge of the causative influence of the typhoid bacillus 
in the production of enteric fever, and of the mode of distribution 
of these germs in the various organs, fails to account adequately for 
the symptoms of the disease. It is probable, though, that certain of the 
intestinal symptoms of enteric fever are due to the direct action of the 



Enteric or Typhoid Fever. 445 

typhoid bacillus ; but the constitutional symptoms, including the fever, 
must be explained by the continuous action of a chemical poison pro- 
duced by the growth and multiplication of these organisms within the 
body; especially is this true of the nervous and vasomotor phenomena, 
the feeble circulation, dicrotism, relaxed capillaries, flushed face, 
dilated pupils, and delirium. 

Anatomically, it is said, it is important to bear in mind that the 
characteristic lesions of typhoid fever, which are in the intestines and 
in the mesenteric lymphatic glands, do not constitute the disease ; but 
that the chemical poison produced by its specific cause is taken up by 
the fluids of the body, and gives rise to general disturbances, which 
are present in all fully-developed cases, and which manifest themselves 
at a very early period in the attack; therefore the anatomical lesions 
fall naturally into two groups. 

The first embraces those arising from the local action of the 
typhoid bacillus and the concentrated ptomaine which they produce, 
and includes changes in the lymphatic system of the intestinal canal. 

The second group includes lesions which are not the direct result 
of the local action of the bacilli, but are due to constitutional infec- 
tion. They consist of degenerative changes involving the tissues of 
the various organs, and are to be found generally manifested through- 
out the body, and particularly in the liver, the kidneys, the voluntary 
muscles, the heart, the salivary glands, and the pancreas. 

The marked disturbances in the function of the nervous system 
indicate profound nutritive derangement, the nature of which is at 
present unknown. 

The changes of the second group are not peculiar to enteric fever ; 
they occur in other acute febrile diseases, and must be ascribed to the 
action of the various special toxic principles to which the phenomena 
of such diseases are due. These anotomical changes attain their fullest 
development in enteric fever, however, for the reason that in this dis- 
ease the organism is continuously subjected to the action of these toxic 
principles for a prolonged period. 

The lesions in childhood are, as a rule, less extensive and con- 
spicuous than in adults, just as the disease itself is less intense. They 
have been also less thoroughly studied, by reason of the favorable course 
of the disease in childhood, and the consequent low rate of mortality. 

The Digestive Tract. — Inflammation of the mucous membrane of 
the stomach is common in typhoid as in other acute febrile diseases. 

The duodenum usually presents no anatomical changes. 

The jejunum and upper part of the ileum may be distended with 
gas; the lower portion of the ileum is usually collapsed. 

The tympany which belongs to the disease is chiefly due to the 
presence of gas in the colon ; invagination of the intestines, unaccom- 
panied by evidence of inflammation, is occasionally met with at one 
or more points. 



446 Enteric or Typhoid Fever. 

The constant and therefore characteristic lesion is an affection 
of the solitary and agminate glands in the lower part of the ileum. 
The lymphatic follicles of the caecum are usually involved, and not 
infrequently those of the colon also. 

First Stage. — The first stage is characterized by a swelling of the 
glands, with surrounding hyperemia. The Peyer's patches project 
above the surface of the surrounding mucous membrane in the form 
of flattened, oval plaques with a reticulated, mammillated surface and 
elevated margins. The solitary follicles, which are not constantly 
implicated, form, when affected, discrete, shot-like projections, varying 
in diameter from one-eighth to one-fourth of an inch. These changes 
are always progressively advanced in the lower part of the ileum, 
reaching their full development in the neighborhood of the ileocecal 
valve. This glandular swelling is due to extensive hyperplasia of the 
lymphatic elements. The cellular infiltration extends downward into 
the submucous tissue, but at the borders of the patches is more 
or less abruptly limited. It attains its maximum about the end of 
the first week. 

Second Stage. — The infiltrated lymphatic tissue now undergoes 
necrosis. The mass changes to a dirty yellow color and becomes more 
opaque, and the lymphatic follicles, with the epithelium covering them 
and some of the surrounding tissue, break down at scattered points, 
so as to form an irregular or ragged ulcerated surface, or en masse 
into one large slough. This slough, stained a deep yellow or brown 
by the intestinal contents, remains attached for a time. It is then 
gradually cast off, either in a single piece or in fragments ; this process 
occupies another week, so that the separation of the slough takes place 
at the end of the second or early in the third week. In the greater 
number of instances of enteric fever in childhood, the sloughs are 
superficial and of limited extent, and the ensuing ulceration under- 
goes prompt cicatrization. 

Third Stage. — The ulcer thus formed, as a rule in adults, but 
exceptionally in childhood, has^i smooth floor, and abrupt and to a cer- 
tain extent overhanging edges. 

Healing of the ulcers begins during the fourth week, and extends 
over a period of a fortnight, the scar becoming covered with epithelium 
and showing no tendency to contraction. In protracted cases the heal- 
ing of the ulcers extends over a longer period, and in relapsing cases 
the stage of medullary infiltration may be renewed, and generally it 
ends in resolution. 

From the detachment of the slough occurs the danger of hemor- 
rhage, which is usually gradual, though sometimes profuse and imme- 
diately fatal. 

In the former case the blood is intimately mixed with intestinal 
contents, or forms a continuous or broken clot ; in the latter the intes- 
tinal contents are liquid blood. Perforation of the wall takes from 
the extension of the ulcer in depth, and is, as a rule, preceded by the 



Enteric or Typhoid Fever. 447 

formation of fibrinous adhesions between the peritoneum at the base 
of the ulcer and that contiguous. The base of the ulcer, if gangrenous, 
yields to the pressure of the intestinal contents or to intestinal peri- 
stalsis and is torn through; thus the intestinal contents escape into 
the peritoneal cavity, causing a general peritonitis. A localized peri- 
tonitis may take place when the sloughing ulcer is in the vermiform 
appendix, or when the peritoneal surface of the intestines is firmly 
attached to the adjacent peritoneum. 

The spleen is also hyperplastic, and during the second week may 
become tripled in size, except when it is atrophied or its capsule indu- 
rated. Hemorrhagic infraction and abscess of the spleen may occur as 
complications. 

The heart, liver, and kidneys show granular degeneration of pro- 
toplasm, characteristic of infectious diseases. The heart is opaque, 
gray, and flaccid ; the liver is enlarged, opaque, gray, the lobular regions 
indistinct. 

Ulceration of the larynx, catarrhal bronchitis, and lobes and lobu- 
lar pneumonia are frequent. Meningitis at times follows a compli- 
cating inflammation of the middle ^ear or acute parotitis. Venous 
thrombosis, especially of the veins of the leg, is not infrequent, and 
sometimes proves a cause of fatal embolism during convalescence 
from the fever. Orchitis sometimes occurs. 

Symptomatology . — In adults, typhoid may begin abruptly with a 
chill; in most cases its development is so insidious that it is almost 
impossible to fix the date of the attack, weariness, malaise, epistaxis, 
headache, slight aching pains in the legs, increasing weakness, and 
accelerated pulse, with slight diarrhea, being the only manifest symp- 
toms. During this stage there is commonly in the evening a slight 
elevation of the bodily temperature, which, as the disease progresses, 
takes upon itself the peculiar almost characteristic temperature rhythm 
of typhoid fever. 

The course of enteric fever in children is not only as a rule much 
lighter, but it also lacks the well-marked sequences of phenomena which 
characterize the evolution of the sickness in the later periods of life. 
We do not recognize in children the distinct periods into which the 
course of the disease in adults is divided more successfully, in accord- 
ance with the stage of development and the successive prominence of 
special symptoms. Nor are we able, as a general rule, to divide satis- 
factorily the febrile movement into the two distinct and well-defined 
stadia, usually seen in adults. As is well known, the first stadium 
corresponds to disturbances of the organism due to special infections, 
and it is in this period that pathologists have been able to recognize 
in the blood and tissues of the body the typhoid bacillus. The fever 
is of the subcontinuous type. The second stadium, on the other hand, 
corresponds to that period of the disease intervening between the forma- 
tion and separation of the intestinal sloughs, and the convalescence. 
The fever, instead of being subcontinuous, is distinctly remittent, and 



448 Enteric or Typhoid Fever. 

presents the characteristic of surgical or hectic fever, which is with- 
out doubt due to an infective process analogous to that which occurs 
in those conditions, and not to any specific action of the typhoid infec- 
tion. 

In children this second stage is imperfectly developed, short in 
duration, often absent altogether, — a modification of the course of the 
fever as seen in adults which is in close accord with the fact that in 
the earlier periods of life, the intestinal lesions frequently undergo 
resolution wholly without ulceration, or more commonly present some 
superficial sloughing and ulceration, and only exceptionally reach the 
higher grade of development which is the rule in adult life. 

To make this more clear, we may consider a corresponding state 
of affairs as regards the course of the temperature presented by scarlet 
fever. When this disease runs its course without complication, the 
temperature curve presents a single stage, and terminates in the course 
of eight or ten days, usually by a somewhat prolonged critical defer- 
vescence. When, on the other hand, it is complicated by secondary 
infection and an inflammatory implication of the parotid gland, the 
middle ear, or the lymphatics of the neck, the febrile movement of the 
primary infection is succeeded by a hectic fever and suppuration, and 
a second febrile stadium shows itself, which may indefinitely prolong 
the sickness. 

In typhus fever we have a fever without constant or distinct local 
lesions; we have a single febrile stage due to the specific infection, 
which usually terminates by the tenth or twelfth day. 

Another usual modification of temperature in childhood consists 
in the greater extent of the morning remissions and the evening exacer- 
bations. There is a ready explanation in the labile tendencies of the 
temperature of childhood under all circumstances, and it is to some 
extent a trait of every febrile disease in early life. 

The well-known tendency of delirium to take its form from the 
development and mental habit of the individual in sickness of every 
kind, will serve to explain the fact that in childhood, apathy, somno- 
lence, and stupor are much more active, or even wandering delirium. 

A stage of prodromes usually precedes the outset of the fever, 
which is so insidiously developed that it is impossible to designate the 
day of its commencement. Patients are noticed to be easily fatigued 
and indisposed to play. They complain of feeling badly, and of head- 
ache, especially frontal headache, which is usually worse toward night. 
They complain also of pain and soreness in the muscles, and the sleep 
is restless and broken. The bowels are, as a rule, constipated; the 
expression is dull, the appetite poor, the tongue coated. This period 
is of uncertain but brief duration ; it gradually merges into the declared 
disease ; slight, irregular chills or repeated attacks of chilliness, may 
mark the beginning of the fever. 

The disease is sometimes preceded by an attack resembling inter- 



Enteric or Typhoid Fever. 449 

mittent fever. Here the fever speedily assumes the remittent type, 
and the charactistic symptoms of enteric fever are developed. 

The attack is to be regarded as beginning with the first chilliness 
or the first rise of temperature; the fever increases, but it is dis- 
tinctly remittent in type, the exacerbations occurring in the afternoon 
or evening and the remissions in the morning. The progressive rise 
in temperature often lacks the regularity seen in adults, nor is the 
rash or acme, which is usually reached by the evening of the fifth 
day, as a rule so high. 

The skin becomes dry and hot; not infrequently, however, espe- 
cially in the early part of the day, it is moist or even bathed in sweat. 
The headache becomes more marked. Epistaxis sometimes occurs. It 
is usually slight, not exceeding a few drops ; at other times it may be 
considerable in amount. The expression is dull and apathetic, the 
countenance pale, and the cheeks slightly flushed. Sleep is more rest- 
less than before, and often disturbed by cries and jactitation. In the 
ordinary cases seen in childhood pronounced delirium is uncommon; 
when present it usually occurs between sleeping and waking and is tran- 
sient. The lips are parched and dry and speedily become fissured and 
scaly. The tongue is usually moist, red at the tip, and covered with a 
whitish-yellow fur, which is sometimes thin, sometimes thick and 
pasty. Appetite is lost, thirst augmented. Constipation is much more 
frequently present in children than in adult life ; nevertheless diar- 
rhea may be present from the period of prodromes until convalescence. 
In the full development of the disease, the abdomen has usually 
some prominence, which is very exceptionally distended or tense. 
There is often tenderness upon pressure, particularly in the region cor- 
responding to the ileocecal valve, and upon palpation gurgling is pro- 
duced. In the majority of cases the spleen is enlarged. Cough, usually 
slight, is apt to be present and upon auscultation a few scattered coarse 
mucous rales may be detected posteriorly. The eruption appears some- 
where between the fifth and tenth days of the attack. It is commonly 
sparse, scattered over the abdomen or lower part of the chest and upon 
the back. It may be absent altogether ; when present, it is charac- 
teristic of the disease. 

The urine, which during the course of the disease is scanty and 
highly-colored, presenting the usual characteristics of fever-urine, 
becomes with the defervescence limpid and abundant. 

Toward the end of the second week the subcontinuous fever of the 
acme assumes a distinctly remittent type, and defervescence takes place 
by rapid lysis. Coincidentally with this change, general improve- 
ment takes place. Defervescence is, as a rule, completed somewhere 
between the tenth and twentieth days, and the child enters upon con- 
valescence pallid, feeble, and emaciated out of proportion to the symp- 
toms of his sickness. Thirst diminishes ; appetite returns ; mental 
anxiety quickens ; and the restoration to health is more rapid than in 
adult life. 

29 



450 Enteric or Typhoid Fever. 

Eelapses occur in a certain proportion of cases in childhood and 
infancy. What proportion can not be stated positively. They appear 
to be much less common than in adult life. 

The relapse constitutes a true second attack of the specific fever. 
It is due to reinfection, probably from some source within the organism 
itself, and is attended by the characteristic phenomena of the disease. 
It is, as a rule, however, of more abrupt onset and shorter duration than 
the primary attack. 

It is to be noted that during this period, in cases in which relapse 
occurs, the spleen remains enlarged. The relapse is not invariably thus 
^separated from the primary attack, but may occur during its course. 
It is then termed an intercurrent relapse; and it is to intercurrent 
relapse that cases of unusual prolongation, in the absence of complica- 
tions, are to be ascribed. Two or more relapses may occur. An attack 
of typhoid fever appears in the great majority of cases to confer 
immunity aganst subsequent attacks. It is said, however, that to the 
immunity often acquired in infancy or childhood the insusceptibility 
of many adults to the disease is to be attributed. 

Very mild cases doubtless frequently escape recognition. The 
little patient, though far from well, continues to play about with its 
companions. These cases do not correspond to the "walking typhoid 
cases" of adult life. 

The intestinal lesions being superficial, the attack is not likely to 
terminate in hemorrhage from the bowels or in perforation. 

PRINCIPAL SYMPTOMS. 
THE TEMPERATURE. 

The typical temperature range, which is of diagnostic importance 
in adults, is rarely seen in childhood. 

Owing to the difficulties of diagnosis at the beginning of the attack, 
which are much greater in childhood than in adult life, and to the 
insidious development of the disease, accurate temperature observations 
of the earlier periods are not often taken. Even when cases develop 
in the families of well-to-do people, and thus come comparatively early 
under the observation of the physician, the morbid phenomena are not 
usually such as to lead immediately to the anticipation of a serious dis- 
ease, nor are there such obvious evidences of fever as to suggest the sys- 
tematic taking and recording of the temperature. 

In those rare instances when the fever begins suddenly with a chill, 
followed by a rise of several degrees in the temperature and sweating, 
there remains the possibility of a previous insidiously-developing febrile 
movement which has been overlooked. In these cases the rise in tem- 
perature following the chill is abrupt, often reaching 103.5 to 104 
degrees Fahrenheit. Much more common is a gradual rise in temper- 
ature, the curve taking the form of an irregular zigzag, and the eve- 



Enteric or Typhoid Fever. 451 

ning exacerbation exceeding the remissions of the following morning by 
about one degree Fahrenheit, so that the fastiginm is reached in the 
later days of the first week. Here the initial is absent, but there is 
often a slight sense of chilliness or transient shivering during the early 
days at the time of the evening exacerbation. The fastiginm having 
been reached, the type of the fever becomes subcontinuous, the differ- 
ence between the evening and the morning temperature being about a 
degree and a half. 

At some time between the end of the second and the middle of the 
third week, or exceptionally even later than this, the type of the febrile 
movement gradually becomes distinctly remittent or even intermittent, 
the remissions and exacerbations being gradually increased. The defer- 
vescence thus assumes the form of a rapid, gradual lysis, the fever ter- 
minating when the evening temperature falls to normal. 

In a considerable proportion of the cases the defervescence takes 
place by a rapid lysis, without the intervention of distinct remissions 
or intermissions, the fall being of an irregular zigzag not unlike that 
which marks the access. Less frequently — and this is especially the 
case where the duration of the fever is relatively short — the defer- 
vescence takes place with considerable rapidity, in itself suggestive of 
crisis. This is the well-known mode of termination in the abortive 
cases seen in adult life. 

In the early days of convalescence the morning temperature, and 
at times the evening temperature also, falls to subnormal ranges. Dur- 
ing convalescence the temperature is exceedingly unstable. Transient 
perturbations, with a rise of three or four degrees to which the term 
recrudescence of fever has been applied, are brought about by slight 
causes, among which are errors in diet, especially the eating of meat 
or fried chicken, constipation, undue muscular effort, and mental 
excitement. 

The temperature range, alike during the fever and during con- 
valescence, is liable to modifications in consequence of complications. 
Abundant loss of blood from epistaxis or from intestinal hemorrhage 
is apt to be followed by a considerable fall of temperature. This fall 
is not permanent unless it occurs during the defervescence. 

The temperature of the disease in children reacts promptly and 
decidedly to antipyretic treatment. The height of the fever in the 
fastiginm is variable. In many cases it does not exceed 102.5 to 103 
degrees Fahrenheit. Exceptionally it reaches 104 degrees or even 105 
degrees. The average difference between the morning and evening tem- 
perature is, as a rule, about a degree or a degree and a half. There is 
occasionally observed a slight exacerbation occurring early in the after- 
noon, followed by a correspondingly slight remission. The maximum 
temperature is reached in the evening. Where, in the course of twenty- 
four hours, two temperature observations only are made, the most con- 
venient time is between seven and eight in the morning and between 
seven and eight in the evening. In grave cases, and where the temper- 



452 Enteric or Typhoid Fever. 

ature is either very high, or shows a tendency to sudden changes of con- 
siderable extent, observations should be taken much more frequently. 
A temperature of inverse type has been occasionally noted. Hyper- 
pyrexia, the temperature reaching 105.8 degrees Fahrenheit, and 
rapidly rising to 108 to 110 degrees Fahrenheit, does not occur in 
uncomplicated enteric fever in childhood. 

TIIE CIRCULATORY SYSTEM. 

In mild cases the action of the heart is but little disturbed; in 
those of moderate severity it is progressively diminished until the 
* impulse and the first sound are much enfeebled. These changes are 
less marked, as a rule, in infancy and childhood than in cases of corre- 
sponding severity in adult life. 

Pericarditis is rare, and is looked upon as a complication when it 
occurs. Actual endocarditis of a mild grade is probably of more fre- 
quent occurrence than the description of the text-books would indicate. 
. Sudden death in the absence of adequate anatomical lesions, such as 
occasionally occurs in adult life, it is said does not take place in enteric 
fever in childhood. The pulse in children corresponds in a general 
way to the height of temperature. The exceptions to this rule are very 
frequent, a pulse of 120, 108, or even 96, being occasionally met with 
where the temperature ranges as high as 103 or 104 degrees Fahrenheit. 

On the other hand, the pulse may be exceeding rapid, reaching 
a frequency of 150 or 180 in cases that terminate in recovery. It is 
sometimes irregular both in rhythm and in force. Picrotism is much 
more rare in childhood than in adult life; but we must, in this con- 
nection, again insist upon the fact that the phenomena of enteric fever 
in later years of childhood closely correspond to those of the disease in 
adult life. 

The peculiarities of the pulse in infancy are said to be due to the 
narrowness of the arteries, which make it difficult to recognize beyond 
. the fact that it is always small and compressible. Extreme irregularity 
of the pulse is a grave symptom. 

During convalescence the pulse is apt to be more rapid than in 
health, and to show marked variation in frequency. It is, on the other 
hand, not rarely slower than normal. 

The oedema of the ankles and legs, often seen in the early days of 
convalescence, must be ascribed to the weakness of the heart and imper- 
fect circulation of the blood. Collapse is rare in childhood. It occurs 
only in the graver cases, and may result, as in adult life, from various 
accidents, among which are intestinal hemorrhage, the shock following 
perforation, or even sudden copious diarrhea or violent vomiting. 

THE RESPIRATORY SYSTEM. 

In the absence of pulmonary complications, the frequency of the 
respiration varies with the intensity of the febrile movement. The 



Enteric or Typhoid Fever. 453 

respiration rises with the pulse, but in cases characterized by an unus- 
ually slow pulse there is no corresponding slowness of the breathing. 

A certain amount of bronchial catarrh is so frequent that it merits 
consideration as a phenomenon of the disease rather than as a compli- 
cation. Cough is much more common in children than in adults, 
although the corresponding physical signs are in many cases not pres- 
ent, a fact to be accounted for by the superficial respiration of child- 
hood and the impaired muscular tone of the disease. For the same 
reason, the respiratory murmur is ordinarily much enfeebled. Upon 
deeper inspiration, such as accompanies crying or coughing, moist rales 
are distinctly heard. In other ca^es dry and moist rales are to be heard 
over all parts of the chest. 

In a majority of the cases the bronchitis is of moderate intensity, 
especially if the patient receives proper care and treatment. In severe 
cases, however, there is frequently developed broncho-pneumonia, which 
manifests itself by notable enfeeblement of the respiratory murmur of 
the dependent portions of the lungs, and by impairment of resonance 
upon percussion. These changes are apt to affect both lungs, although, 
as a rule, the signs are somewhat more pronounced upon one side than 
upon the other side. They are largely due to the condition of the 
nervous system. The patient expectorates little, is apt to swallow 
food the wrong way, and lies quietly upon his back. This form of 
pneumonia occurs during the acme of the febrile movement, or early 
in the defervescence, and frequently amounts to a complication which 
prolongs the febrile process. 

Hypostatic congestion also occurs in consequence of the feeble cir- 
culation; it is limited to the posterior parts and bases of the lungs. 

Fibrinous pneumonia rarely occurs as early as the second day, or 
even during the first week, and it may attack the lower as well as the 
upper lobes. In cases where it comes on very early, the diagnosis is 
for a time obscure. It may sometimes occur during convalescence. 
It remains an open question as to whether or not this form of pneu- 
monia, occurring in the early period of the disease, is due to a pul- 
monary localization, or to an independent coincident infection. 

The same statement is said to be true of pleurisy with fibrinous, 
serous, or purulent exudation, — a complication, however, which is rare. 

Henock has noted in a girl aged four years the occurrence of gan- 
grene of the lung in pneumonia occurring as a complication of enteric 
fever. 

Catarrhal laryngitis with hoarseness, due to the same causes that 
produce the bronchitis, is occasionally encountered. Ulceration of the 
vocal cords or of the posterior wall of the larynx, are more rare in this 
country than in Europe. (Keen.) Perichondritis of the arytenoid 
cartilages has also been observed. This is a complication of grave 
import, and may lead to rapid development of oedema of the glottis. 
Facial and laryngeal diphtheria may also occur as complications. 
Stenosis of the larvnx mav occur as a result of, first, cedematous larvn- 



454 Enteric or Typhoid Fever. 

gitis ; second, ulcerative laryngitis ; and third, laryngeal perichondritis. 
In ninety-four cases collected from various sources by Keen, in which 
the age is regarded, six were under the age of fifteen years. Ulcera- 
tion of the nasal cartilages, resulting sometimes in perforation of the 
septum, sometimes in a permanent deformity of the nose, also occurs. 

THE DIGESTIVE SYSTEM. 

In the digestive organs the symptoms of disturbances are much 
the same in childhood as they are in adult life. Loss of appetite dur- 
ing the progress of the fever is the rule ; upon the occurrence of conva- 
lescence, there is usually marked hunger. Thirst is a prominent symp- 
tom, but it is generally of moderate amount and readily gratified. 

The tongue is moist, and is, in exceptional cases, clean throughout 
the attack. It is much more commonly red at the tip and edges, and 
covered with a pasty, yellowish-white fur, which is apt to separate in 
the course of the disease, leaving the tongue smooth, bright red, and 
dryish. We do not, as a rule, find in childhood the hard, dry, brown 
tongue which is so common in the later stages of the disease in adults. 
Sordes upon the teeth and gums are not common in childhood ; the lips 
are apt to become cracked and fissured, with the formation of super- 
ficial crusts ; superficial apthous ulcerations likewise occur upon the 
tongue, upon the buccal mucous membrane, and at the corners of the 
mouth. 

Vomiting, sometimes spontaneous, sometimes following the admin- 
istration of food or medicine, occurs much more frequently in children 
than in grown persons ; but this symptom is more common in the first 
week of the attack, and may occur from time to time throughout the 
whole course of the disease. 

Repeated vomiting occurring at the beginning of the attack tends 
to increase the resemblance between enteric fever and tubercular menin- 
gitis, and renders the diagnosis for the time somewhat obscure. 

The condition of the bowels is extremely variable, constipation 
being about as frequent as diarrhea in the beginning of the attack. In 
many cases the bowels are almost normal as regards the frequency of 
the movements and the consistency of the dejections throughout the dis- 
ease. When constipation exists in the beginning of the disease, it is 
liable to give way to a more or less frequent diarrhea on the later 
course. The number of passages may vary from one to ten, even fif- 
teen or more, in twenty-four hours. When the movements are fre- 
quent, the dejections are often formed of a mushy consistence, being 
usually of a lightish-yellow color ; when diarrhea is present, they usually 
present the well-known thick a pea-soup" appearance, and divide, upon 
standing, into an upper cloudy-liquid layer, and a lower layer com- 
posed of greenish-yellow masses. The discharge from the bowels is 
sometimes of a rather bright greenish color. 

Diarrhea, when present, is apt to continue until defervescence is 



Enteric or Typhoid Fever. 455 

completed, and to be succeeded during the convalescence by constipa- 
tion, which, when obstinate, is not infrequently a cause of transient 
recrudescences of the fever. On the other hand, it happens occasionally 
during convalescence that spontaneous diarrhea occurs. 

Except in the case of very young infants, involuntary evacuation 
of the bowels or bladder in bed is unusual. Later, in the course of 
severe cases, involuntary discharges are apt to take place. The belly is 
often slightly sensitive, but tenderness is extremely rare. It is more 
apt to be present in constipated cases. It is more difficut to determine 
the presence or absence of local tenderness upon pressure in the ileo- 
cecal region in children than in adults. For this reason the symptom 
is less important. The abdomen is usually normal in contour or mod- 
erately distended ; in some cases it is flat. Marked tympany is com- 
paratively rare in childhood. 

Abdominal pain is usually absent. Sharp attacks of colic, espe- 
cially just before an action of the bowels, occur occasionally. 

Intestinal hemorrhage occurs as the result of the implication of 
the walls of the blood-vessels in the ulcerative process. It is apt to 
occur at the time of the separation of the sloughs, namely, comparatively 
late in the course of the attack. 

Hemorrhage from the bowels is in all eases a significant symptom. 
Even slight hemorrhage may be followed after some hours or days by 
a dangerous or fatal loss of blood. 

After every intestinal hemorrhage of considerable amount, the 
anaemia characteristic of the period of the disease in which this acci- 
dent is liable to occur, is intensified, and signs of collapse are apt to 
appear. The fall of temperature amounts, usually, to two or three 
degrees Fahrenheit, and may reach normal or even subnormal ranges. 

Hemorrhage, even when large, does not necessarily result in a fatal 
issue of the case. Cases are reported where the hemorrhage seems to 
have exerted a favorable influence upon the cerebral symptoms, and 
occasionally it is followed by improved intelligence, permanent reduc- 
tion of fever, and other signs of beginning convalescence. Very rarely 
the perforation of the floor of an ulcer into the peritoneal cavity occurs 
in children. If it does occur, it is apt to be late in the course of the 
attack. 

Peritonitis may occur through direct extension of the intestinal 
ulceration of the serous membrane without actual perforation. Peri- 
tonitis arising in this manner may be either local or general. If the 
slightest amount of extravasation of the intestinal contents should find 
its way into the peritoneal cavity by the means of a perforating ulcer, 
there results a purulent or even an ichorous peritonitis, with the well- 
known symptoms of an attack of this form of serous inflammation. 
Abdominal pain, distention, collapse, eructations, and vomiting, a small 
and frequent pulse, rapid fall of temperature, followed by an abrupt 
rise and great fluctuations, constitute the two familiar clinical symp- 
toms of this accident. 



456 ♦ Enteric or Typhoid Fever. 

Enlargement of the spleen in enteric fever is looked upon as of 
some diagnostic importance. The splenic tumor may be made out as 
early as the third or fourth day ; in many instances, not until the sixth 
or seventh or ninth day. The more rapid the rise of temperature, the 
earlier the spleen becomes enlarged. The enlargement of this organ 
subsides with defervescence; exceptionally the spleen remains enlarged 
for some days after convalescence is established. 

Pain in the spleen is rare; it may result from laceration of a dis- 
tended capsule. 

3. THE NERVOUS SYSTEM. 

The symptoms of disturbance of the nervous system are, as a rule, 
much less marked in infancy and childhood than in adult life. In some 
cases there are no nervous symptoms present throughout the whole 
course of the disease, though in a great number the nervous disturb- 
ances are manifested. Headache, increased toward evening, frequently 
occurs during the prodromic period and the first week of the disease. 
It is commonly referred to the forehead or temple, but it may affect 
the whole head ; it is occasionally neuralgic in character, and may be 
intense ; it usually subsides about the end of the first week. 

In cases of moderate severity, the child lies with its eyes half 
closed, lightly somnolent, sometimes restless. When spoken to, it often 
turns away or answers in monosyllables, with evidences of irritation. 
Often, even in advanced childhood, the patient refuses to show the 
tongue, or, if it is showing, forgets for a few moments to draw it in 
again, unless told to do so. There is dulness of hearing, sometimes 
amounting to marked deafness. Dilatation of the pupils is common ; 
sleep is restless and disturbed. Sometimes sleeplessness is a distress- 
ing symptom. Oftentimes dizziness is complained of. We also 
observe among the nervous symptoms cutaneous hypersesthesis, which is 
often quite extensive. 

Delirium is usually mild. It is more apt to occur in the evening 
or toward night, and is sometimes associated with night terrors. The 
common form in childhood is the so-called wandering delirium; it is 
apt to be transient and recurrent rather than continuous. The severer 
forms are not frequent, and are indications of grave cases. Sudden, 
sharp, and prolonged outcries are observed in children, with excitement 
not easy to pacify. In children at the age of puberty especially, the 
disturbances of the nervous system are often fully developed, so that 
we encounter active delirium accompanied by efforts to leave the bed; 
deep stupor, tremor of the hands and tongue, and slight twitching of 
the muscles of the face and of the tendons of the wrists and hands, also 
occur. Subsultus tendinum is the name given by the older writers to 
these motor disturbances. Grinding of the jaws occurs as an ominous 
symptom. Persistent tremor of the extremities and of the lower jaw 
is apt to be associated with increased tendon reflexes and mechanical 
excitability of the muscles. In deep coma the muscles become lax, the 



Enteric or Typhoid Fever. 457 

movement of the eves is no longer coordinated, reflex excitability is 
diminished, involuntary evacuation of the bowels takes place, and 
there is often retention of the urine. 

Peraplegia, hemiplegia, and paralysis of the muscles of the eye 
and of the larynx are very rare. These accidents usually occur during 
convalescence; their tendency is to recover. 

Aplasis is much more common in children than in adults. It is 
often complete. It usually appears during the fever period of defer- 
vescence or in the early days of convalescence, never during the height 
of the fever. It usually passes away gradually in the course of ten 
days or two weeks. As Bowers has pointed out, "'Although there is 
almost complete speechlessness, there is no disorder of speech or partial 
loss of speech, such as occurs in cases of organic disease of the brain." 

THE URINE. 

Transitory albuminuria occurs with sufficient frequency to merit 
consideration as a symptom rather than as a complication. Bouchard 
has pointed out the fact that the bacillus typhosus is found only in 
albuminous urine. Enteric fever differs from scarlatina in the 
extremely rare occurrence of acute nephritis as a sequel. Retention of 
the urine is much less common in childhood than in adult life, although 
it occasionally occurs ; catheterization is then necessary. Great care 
must then be used in keeping the catheter very clean, as vesical catarrh, 
urethritis, and epididymitis are liable to result from want of antiseptic 
precautions. Polyuria has been observed in the course of the disease 
in children. 1 

Menstruation in girls at puberty is apt to be profuse and pro- 
longed. In the case of a girl fourteen years of age, which is recorded, 
menstruation occurred for the first time during the attack and con- 
tinued for a fortnight. This case was one of great severity, and ter- 
minated fatally. 

THE. SKIN. 

The rose-colored spots peculiar to the disease differ in no respect 
from the eruption as seen in adults. They are to be looked for upon 
the abdomen, the lower part of the chest, and between the shoulder- 
blades ; occasionally they are found on the inner surface of the thighs. 
As a rule, they are not numerous. The appearance of the eruption is 
usually coincident with the occurrence of the splenic enlargement. The 
eruption may sometimes be found as early as the fourth or fifth day, 
especially if the fever appears suddenly and increases rapidly in 
intensity. Sudamina (vesicles) occur in childhood as in adult life, 
due to free sweating, which occurs in the later period of the febrile 
movement. 

True petechia? rarely occur. They are of unfavorable prognostic 
import. 

lu Diseases of the Nervous System," Amer. Ad.. 1888. 



458 Enteric or Typhoid Fever. 

Boils may occur ; and abscesses in the integuments, the muscles, or 
the intramuscular connective tissue, are met with infrequently. Sup- 
puration of the lymphatic glands of the axilla or in other regions may 
also occur. Superficial bed-sores may occur in children who are not 
carefully nursed. The hair falls out during convalescence. The nails, 
both of the hands and of the feet, show transverse markings that indi- 
cate impaired nutrition of the tissues during the attack. 

Facial erysipelas occasionally occurs at the end of the attack or 
during convalescence in children as in adults ; in children, it is a much 
less serious complication. It is apt to terminate critically in the course 
of four or five days. Gerent 1 collected sixty-four cases out of 3,910 
cases at all ages, observed by various clinicians. 

Suppurative otitis media, generally called one-sided, is by no 
means an infrequent complication. It is usually of moderate intensity, 
and if properly cared for, terminates in complete recovery during con- 
valescence from fever. 

Lesions of the Osseous System. — Inflammatory changes in the 
bones are relatively common in infancy and adolescence. The symp- 
toms are local. There is pain, at first vague, speedilv becoming local- 
ized, usually severe, lancinating, aggravated at night often to such a 
degree as to render sleep impossible. The pain is associated with 
great tenderness. Localized tumefaction of the soft parts, with or 
without redness, speedily follows. After a time fluctuation appears, 
and one or more fistulous openings are formed, which discharge a 
small quantity of pus. The sinuses frequently close spontaneously, 
only to open again. The usual termination is in suppuration and 
necrosis. 

Lesions of the bones are more common during convalescence from 
prolonged attacks. They are due to disturbance in the blood supply. 
Traumatism is said to play only a secondary part in their causation. 
Early surgical intervention is urgently demanded. Spontaneous dis- 
locations are among the rare accidents of enteric fever in childhood. 
They have been described by Keen, who collected forty-three cases, at 
all ages, in which spontaneous dislocation occurred, — twenty-seven 
times in the hip, twice in the shoulder, and once in the knee. Fifteen 
of the hip cases occurred in enteric fever, and of these a number were 
in children under fifteen years of age. 

Complications and Sequeli. — In the foregoing analysis of the 
special symptoms it has been necessary to allude frequently to compli- 
cations of enteric fever ; only a few additional remarks are now neces- 
sary. 

It has been said that no hard and fast lines can be drawn between 
the complications of an acute febrile disease and the mere intensifica- 
tion of certain processes with corresponding prominence of local symp- 
toms. Intestinal hemorrhage, perforation, and peritonitis are all 
regarded as complications. Atrophy of muscles, abscess of muscles, 
parotitis, and nephritis are in the category of sequeli. "The category 
to which hypostasis, oedema, thrombosis, embolism, and infarction, with 

ir These de Paris, 1883. 



Enteric or Typhoid Fever. 459 

the result, should be referred is a matter of opinion. Whether these 
processes should be regarded as belonging to the primary disease, or 
as complications of it, would depend, to a great extent, upon the prom- 
inence of the morbid phenomena to which they give rise. On the other 
hand, pneumonia, erysipelas, phlegmonous abscesses, diphtheria, and 
other septic processes, are obvious complications, concerning the rela- 
tion of which to the original disease there can be no question." 

Scarlatina may immediately precede, coexist with, or follow 
enteric fever. Taupin, Murchison, and others have recorded instances 
in which patients suffering from scarlet fever have developed enteric 
fever, or in which the enteric fever has merged into scarlatina, and 
other instances in which the eruptions of the two diseases have coex- 
isted. 

The writer has known measles to develop during the course of 
typhoid fever. 

Cases of pertussis are reported to have occurred during a course 
of enteric fever. 

The coexistence of diphtheria and enteric fever is much more 
frequent. 

Tuberculosis occurs during or immediately after enteric fever; 
hence pulmonary phthisis is not a rare sequel. Tuberculous menin- 
gitis and tubercular ulceration of the intestines are also encountered 
as sequels. 

Diagnosis. — In well-developed cases of typhoid fever in childhood, 
after the first week it is not usually difficult to diagnose. During the 
first week, however, it is often impossible to form a positive diagnosis. 
The nature of the disease may be suspected if there are febrile move- 
ments, with nocturnal exacerbations each night attaining a higher tem- 
perature, and especially if there are bleeding at the nose, diarrhea, either 
spontaneous, or readily produced by laxative, appreciable enlargement 
of the spleen, and headache. 

The diagnosis of the developed disease rests upon the continuance 
of the febrile movement and the "appearance of abdominal symptoms, 
namely, diarrhea, abdominal pain, moderate tympany, enlarged spleen, 
and gurgling of the bowels. If in addition to these symptoms, rose- 
colored spots appear, the diagnosis becomes certain. The importance 
of the light shed upon doubtful cases by coincident or recently preced- 
ing local epidemics or house epidemics of the enteric fever, must be 
remembered. 

The differential diagnosis from other febrile disorders which more 
or less closely resemble enteric fever is, in the absence of the char- 
acteristic eruption and the abdominal symptoms, sometimes attended 
with considerable difficulty. 

The diseases with which typhoid fever in childhood is likely to be 
confounded, may be divided into two groups ; first, those which resem- 
ble it in the first week of its course ; and, secondly, those which resemble 
it in its more advanced stages. To the first group belong simple con- 



460 Enteric or Typhoid Fever. 

tinned fevers and the exanthematous diseases. Diarrhea is not, how- 
ever, present in these diseases, nor is their ontset characterized by the 
occnrrence of marked prodromes. Furthermore, the character of the 
temperature range of all these affections differs greatly from that of 
enteric fever, being marked by an abrupt rise which lacks the distinct 
morning remissions of the typhoid and attains its maximum with 
greater rapidity. Moreover, simple continued fever comes to an end 
in less time than is required for the full development of typhoid fever. 
The exanthemata can not be distinguished from enteric fever with abso- 
lute certainty in their pre-emptive periods; notwithstanding this, the 
presence of naso-pulmonary catarrh in a doubtful case would lead us 
to suspect measles, or a sore throat would lead us to suspect scarlet 
fever, while the intensity of the febrile movement and the lumbar pain 
in smallpox serve to distinguish it in its early stages from enteric fever. 
After the first week, typhoid fever may in some instances be com- 
plicated or confounded with the following diseases: Remittent fever, 
smallpox, enterocolitis, peritonitis, meningitis, tuberculosis, and trichi- 
nosis. 

REMITTENT FEVER. 

Typhoid fever and remittent fevers not infrequently prevail 
together in malarial countries, and physicians practising in such regions 
are familiar with the form of the fever frequently designated typho- 
malarial, which is, in fact, enteric fever modified by malarial influ- 
ences. On the other hand, severe remittent fever not infrequently 
presents clinical resemblances to enteric fever, particularly when com- 
plicated with marked intestinal symptoms. Thus, vomiting, diarrhea, 
splenic enlargement, cerebral symptoms, and the condition known as 
the typhoid state, may occur in both diseases. The more important 
points of distinction are found in the eruption and the subcontinuous 
or imperfectly remittent character of the temperature range in the sec- 
ond week of enteric fever and its longer course. 

Occasionally there are reported cases where typhoid fever has run 
its course without the characteristic rose-colored rash. In view of this 
fact that in a small proportion of cases the eruption does not occur, the 
rash loses its diagnostic value in doubtful cases. 

Murchison states that he has frequently known a copious eruption 
of lenticular spots to be mistaken for smallpox. The eruptions are 
generally unlike ; they differ in date of appearance, in character, and in 
evolution. The rose-rash of typhoid rarely appears earlier than the 
sixth or seventh day of the illness, and it is only in exceptional cases 
that the rash is present upon the face. It disappears on pressure, and 
undergoes little or no change from the time of its appearance until it 
begins to fade ; that of variola appears during or after the third febrile 
exacerbation of the initial stage, that is, upon the third day of the dis- 
ease. Smallpox shows itself first upon the face and hairy scalp. From 
the beginning it is hard, shot-like, and acuminate : it undergoes char- 



Enteric or Typhoid Fever. 461 

acteristic and unmistakable changes with great rapidity, and it leaves 
a more or less persistent conspicuous scar. 

Influenza occasionally closely resembles enteric fever ; pulmonary 
catarrh, deafness, epistaxis, and dried tongue are seen in both diseases. 
The differential diagnosis rests chiefly upon the occurrence of influenza 
in widespread epidemics, the short duration of the attack, the atypical 
temperature curve, and the absence of the eruption and the abdominal 
symptoms that are usually associated with the diarrhea in typhoid 
fever. 

Enteritis and entercolitis may be confounded with enteric fever. 
These are, however, local diseases, the fever and constitutional dis- 
turbances of which are symptomatic. The spleen is not commonly 
enlarged ; there is no rose-colored rash ; the abdominal pain is more 
conspicuous and severe than that of enteric fever ; and the whole attack 
is comparatively of short duration. 

Peritonitis, due to other causes than perforation, is to be discrim- 
inated from that arising from typhoid fever by the antecedent history 
of the case. 

Meningitis, whether secondary or occurring in the form of epi- 
demic or sporadic cerebro-spinal fever, presents marked points of differ- 
ence from enteric fever ; yet this disease has in some instances been at 
first mistaken for it. The differential diagnosis would be determined 
by the abrupt outset, the acute headache, the frequent vomiting, the 
constipation, the irregular temperature curve, the rapid evolution, and 
the herpetic and petechial eruptions of meningitis. 

Acute tuberculosis presents many points of resemblance to enteric 
fever. The chief points of difference are these: In enteric or typhoid 
fever the temperature range is typical, or more or less conformed to a 
definite type, whereas that of tuberculosis is extremely irregular. In 
enteric fever diarrhea and some degree of tympany are common; in 
tuberculosis, diarrhea is rare, and the abdomen is apt to be flat and 
often scaphoid. In enteric fever, epistaxis, in the early part of the dis- 
ease, is likewise rare, and the headache of enteric fever, as was pointed 
out by Dr. Jenner, disappears upon the occurrence of delirium, or may 
alternate from the beginning. 

TRICHINOSIS (TRICHINA). 

In trichinosis there is pyrexia, with vomiting and diarrhea. The 
rose spots do not occur, and epistaxis and enlargement of the spleen are 
rare, while, on the other hand, the severe muscular pains and tender- 
ness due to the myosis peculiar to the disease, and the local and gen- 
eral oedemas which are almost constant symptoms in trichinosis, are 
absent in enteric fever. 

Prognosis. — The death-rate among children in the first year of life 
is high, especially among the new-born. Statistics show/ taking all 
cases together, that the mortality in childhood is decidedly lower than 
in adults. 



462 Enteric or Typhoid Fever. 

Previous poor health of the patient tends to make the prognosis 
unfavorable, such as hereditary syphilis, local or pulmonary tubercu- 
losis, chronic catarrhal bronchitis, previous unwholesome sanitary sur- 
roundings, improper food, — any cause tending to impair the powers of 
resistance of the organism, as do also the intensity of the infection as 
manifested by the rapid development of severe symptoms, intense 
pyrexia, failure of heart-power, ataxic phenomena, and the occurrence 
of multiple cases in the same house or in the immediate locality. Intes- 
tinal symptoms of a high grade, as copious diarrhea, metarism, abdom- 
inal pain and the like, also prolonged and intractable vomiting, have 
an ominous prognostic import. Finally, complications, as intestinal 
hemorrhage, perforation, local or general peritonitis, ulcerative endo- 
carditis, meningitis, nephritis, diphtheria, croupous pneumonia, and 
pleural effusions, render the prognosis extremely grave. 

Treatment. — This demands separate consideration, and we will 
consider, first, prophylaxia ; second, general management of the patient 
and diet ; third, special forms of treatment and the treatment of symp- 
toms, complications, and sequels ; fourth, the management of the patient 
during convalescence. 

Prophylaxia. — A knowledge of the cause of enteric fever and the 
ways by which the disease is propagated, warrants the confident belief 
that it may not be greatly restricted in its prevalence, but may even be 
ultimately stamped out altogether. As in a vast majority of cases the 
typhoid bacillus finds access to the patient in drinking water, whenever 
there is an epidemic the water should be boiled for some minutes, or 
that which has been bottled and brought from some distant spring 
should alone be used. 

The dejections should always be received into a bed-pan which has 
been previously disinfected with chlorinated lime, or a ten-per-cent 
solution of carbolic acid. If the lime is to be used, one-fourth of a 
pound of chlorinated lime is the quantity that should be placed in the 
pan ; if the carbolic acid solution, one-half pint of a ten-per-cent solu- 
tion will be sufficient to place in the pan before it is placed under the 
patient. When it is possible, the bed-pan should be emptied into a 
large receptacle containing a large amount of chlorinated lime, so that 
it shall be impossible for the bacillus to escape destruction ; if an ordi- 
nary cesspool or water-closet is used for emptying the pan into, the f seces 
should stand for half an hour before being emptied, so as to insure the 
killing of all the germs. After emptying the bed-pan, it should be 
thoroughly washed with carbolic acid of five or ten-per-cent solution. 
There is little or no choice between the two germicides above mentioned. 
Care is necessary to see that the chlorinated lime is of good quality, and 
that it is used with sufficient freedom. 

The bed and body linen of the patient should be changed daily and 
always immediately whenever they are soiled. Just as soon as they 
have been taken off, they should be tied tightly in a clean sheet and put 
into boiling water and boiled for not less than half an hour before open- 



Enteric or Typhoid Fever. 463 

ing the boiler. If the circumstances are such as require the clothes to 
be sent away for washing, immediately after tying them up, the bundle 
should be thrown into a five-per-cent solution of carbolic acid and 
allowed to soak at least six hours before rinsing. In case of death a 
ten-per-cent solution of carbolic acid should be immediately injected 
into the rectum, and the corpse should be wrapped in a clean sheet wet 
with a three-per-cent solution of carbolic acid. 

When it is practicable, the mattress and pillows should be protected 
by rubber covers. If the mattress is fouled by discharges, it should be 
soaked in carbolic-acid solution, and then taken to pieces. Under no 
circumstances should proprietary disinfectants be used; they are all 
more or less uncertain in action and greatly excessive in price. (Fitz.) 
A privy-vault requiring disinfection may be treated with two or three 
pounds of corrosive sublimate dissolved in a large quantity of water 
and slowly poured into the vault. During an epidemic, chloride of 
lime should be freely sprinkled over the surface of the contents every 
day. 

Prolonged boiling will destroy the vitality of all known disease 
germs. There is no way better than disinfecting all clothing used about 
typhoid cases by means of boiling, — corrosive sublimate 1 to 1,000, or 
sulphate of copper of 1 to 100, or carbolic acid of 1 to 50, or chloride of 
lime of 1 to 100. The bleaching properties of chloride of lime must 
not be overlooked. Clothing should not be allowed to accumulate in 
a sick-room. Look to faulty drainage — that there is no pollution of 
drinking water. All foul places about the premises should be disin- 
fected with chlorinated lime and left disinfected, especially during the 
epidemic. The milk and water should be thoroughly sterilized before 
using it during an epidemic. 

THE GEXEEAL MANAGEMENT OF THE PATIENT AND DIETETICS. 

The successful treatment of typhoid or enteric fever in childhood is 
largely dependent on the attention which is given to the general man- 
agement and nursing of the patient. In the first place see that the 
patient is not exposed to any further action of the poison. If the 
original source of the infection is found upon inspection to be connected 
with faulty sanitary arrangements in the house or in the neighborhood, 
it may be necessary to remove the patient to more favorable surround- 
ings. 

In private practise among the well-to-do classes, children commonly 
come under observation during the prodromic period, or early in the 
first stage of the disease. If the fever has already declared itself, the 
use of the thermometer will put the physician upon his or her guard 
as to the nature of the sickness. If in cases seen during the period of 
prodromes the symptoms are such as to excite a suspicion as to the nature 
of the disease, the patient should be put in bed. Should the malady 
prove to be in fact a simple ailment, nothing is thus lost ; if, on the 
other hand, the symptoms subsequently prove to have been those of the 



464 Enteric or Typhoid Fever. 

forming stage of enteric fever, early rest in bed can not fail to influence 
favorably the subsequent course of the attack. The strict rules in 
regard to absolute rest in bed, and to the use of the bed-pan and urinal, 
which must be enforced in adults, can not be well carried out in cases 
of young children. 

The room should be large and well ventilated; the temperature 
should range from 66 to 70 degrees Fahrenheit. It is desirable that the 
apartment should be heated by an open fireplace rather than by furnace 
heat. Thorough ventilation must be secured both day and night, and 
direct draughts are to be strictly avoided. 

x It must be impressed upon the attendant that fever patients are not 
likely to take cold. The bedcovering should be light ; the body should 
be sponged twice a day with water containing aromatic vinegar or alco- 
hol in small quantities. Among the minor duties of the nurse, which 
are not, however, of inferior importance, are the frequent changing 
of the position of the patient's body as will be restful to the little suf- 
ferer, moistening the child's mouth with cold water, cleansing the 
tongue, the prevention of the accumulation of sordes on the teeth and 
tongue, and most scrupulous care of the person in every respect. 

If the evacuation of the urine and faeces in bed can not be pre- 
vented, the discharges and soiled clothing are to be changed without loss 
of time and immediately disinfected. In severe cases we may have to 
use two bed-pans, the patient being lifted from one to the other. 

Fluid is to be administered freely. The best drink is pure water ; 
partially peptonized milk, when not repugnant, is advantageous ; butter- 
milk is especially serviceable ; it may be diluted with one-fourth water 
where it is very thick. When, at the age of thirteen years, the writer 
had typhoid fever, she lived for over three weeks almost entirely on 
buttermilk partly diluted with water. The milk was fresh-churned 
daily. The f koumiss matzoon for a portion of the milk is often relished 
by the patient. Kaw eggs given in sherry or with milk in the form 
of eggnog, are often very well borne, and are very nutritious. The 
various animal broths may be used as adjuvants to milk, but are not 
to be relied upon as affording much nutrition ; beef essence is more stim- 
ulating than nourishing. All meat essences should be freshly made. 
No artificial food should be allowed to remain in the sick-room. 

A record should be kept in all cases of the quantity of food taken 
during the twenty-four hours, so the physician can judge exactly what 
has been taken. During the day, food should be given every two hours. 
In the night it is better to arouse the patient at intervals of every four 
hours. The skill of the physician comes in here — to judge whether it 
is better to arouse the patient from a semi-stupor and administer food 
to prevent exhaustion, or to let the patient sleep where there has been 
much insomnia or wild delirium. The physician should prepare a 
written schedule for the nurse, because so often in the country there 
are no trained nurses. With written directions the mother will be 
more accurate in carrying out the instructions given her as to the times 



Enteric or Typhoid Fever. 465 

of feeding, administration of medicines, etc., and if this is so arranged 
that food is given at 10 p. m., 2. a. m., and 6 a. mc., there will be very 
litle disturbance of the patient during the night. When the food and 
stimulants are given at these long intervals, they should be given in 
larger amounts ; and if the exhaustion of the patient is severe, the inter- 
vals should never be longer than three hours during the night. 

It is impossible to lay down with any accuracy rules as to the 
amount of food ; the object is to get all the food possible digested, and 
put none in the alimentary canal which can not be digested. Most 
adult patients will take two quarts of milk, or milk food, as butter- 
milk or koumiss, with four eggs, in twenty-four hours. Some adults 
require much more, some less. Sick stomach, excessive tympanitis, 
excessive diarrhea, and above all the appearance of curds or other par- 
ticles of undigested food in the stools, indicate that the patient is tak- 
ing more food than can be digested. Under these circumstances, pep- 
tonized foods are especially valuable, and it may become necessary to 
withdraw the milk temporarily, and sustain the patient with animal 
broths. We have known milk and champagne to be taken by the stom- 
ach when it would retain no other food. Coffee, tea, and even cocoa 
are rarely in themselves harmful, and may sometimes be used with 
great advantage in adult cases for the purpose of getting a patient to 
take milk, when otherwise milk is repulsive to the palate. Cold water 
may be given freely, or cracked ice is preferable in case a patient is 
taking three quarts of liquid in twenty-four hours, as much water 
might upset the stomach with an excess of fluid. In most cases the 
various liquid foods given cold will be more grateful, especially in the 
hot season in the southern states, where typhoid fever is very common. 
It is rarely the case that the stomach will not tolerate cold foods. 

Alcohol, according to our belief, should be used in some form in 
every case of typhoid fever from the beginning, unless there should be 
some strong moral reason for refusing it, as when there is a distinct 
heredity toward drunkenness. Given properly, it is incapable of 
harm. There are two distinct uses of alcohol in typhoid fever and 
other adynamic diseases. Early in the attack, given in small amounts 
with the food, it acts as a local stimulant to the digestive organs, which 
so much need it, and enables the patient to take more food than would 
be otherwise possible ; while in the advanced stages of the disease it is 
useful as a general stimulant, and should be given freely, if necessary, 
with the food, and also at other times if indications call for it. In the 
first week of an ordinary case of typhoid fever a tablespoonful of 
whisky in a tumblerful of milk is a full dose for an adult, one ounce 
to two ounces of whisky being given in twenty-four hours; in the 
advanced stages ten or twelve ounces of whisky may be given in twentv- 
four hours if considered necessary. Beyond this amount it would not 
be advisable to give it. The physicians, of course, are guided by the 
effects as well as by the degree of existing exhaustion. So long as the 
pulse under the use of the spirits becomes slower and steadier, and the 

30 



466 Enteric or Typhoid Fever. 

tongue more moist, and the nervous symptoms less severe, so long it is 
probably doing good, and the patient should be gradually withdrawn 
from its use during convalescence. Whenever the patient flushes or 
becomes nervously excited after a single dose, or whenever the odor 
of the liquor appears on the breath, or the pulse takes on the peculiar 
angry feel which every experienced practitioner must know, too much 
of the spirits is being taken. Stimulants should be given at short 
intervals and in small quantities, usually every two hours during the 
day, every three or four hours during the night, the night portion 
being larger than the day allowance. 

t In children alcoholic stimulants are not so much needed in enteric 
fever. In the later stages the indications which call for their adminis- 
tration are twofold; first, great and general prostration, as manifested 
by weakness of the heart's action; secondly, a feeble or scarcely per- 
ceptible cardiac pulse and a correspondingly faint, almost inaudible, 
systolic sound, call for their administration; while such evidence of 
nervous prostration as marked delirium, stupor, tremor, subsultus ten- 
dium, and the like, are best combated by the use of stimulants. Alcohol 
is also indicated where the symptoms which attend extensive and deep 
intestinal ulceration, such as frequent diarrhea, tympany, and great 
tenderness, are marked. We can not lay down any set rule as to the 
amount for a child. It must be given according to the age of the child, 
and according to the child's general condition. It may be administered 
in milk, a half teaspoonful to a dessert-spoonful to a child five or ten 
years old, as required, at short intervals of every two or three hours 
during the day. 

The most important part of the treatment of typhoid fever is that 
which relates to the reduction of the temperature. The external appli- 
cation of cold stands first ; so soon as a patient reaches the temperature 
of 102 degrees Fahrenheit, he should be sponged freely with cold water. 
Antipyrine, phenacetine, and guaiacal act well in typhoid fever, but they 
may cause a collapse. Some writers think they are capable of doing 
harm in typhoid fever by disturbing the nutritive processes of the body ; 
others think it remains a matter of pure conjecture. If used at all, 
they should be employed in small closes, simply for the purpose of hin- 
dering the rise of temperature in those cases in which the baths would 
otherwise have to be given at short intervals. 

It is said that the extreme use of the cold will always reduce the 
mortality rate to three or four per cent. When the temperature reaches 
102 degrees Fahrenheit, the patient must be freely sponged with cold 
water, the body being freely exposed to the air while the process is 
being carried on. If the temperature rises to 102.5 degrees Fahren- 
heit, the cold pack should be used. The naked body of the patient may 
be wrapped in a sheet wrung out of ice-water (if in the country where 
ice can not be obtained, cold well or spring water may be used), and 
placed on a rubber-covered cot or bed, and pieces of ice so placed that 
their outflow shall spread over the sheet and keep it cool. When a 



Enteric or Typhoid Fever. 467 

fever patient is wrapped in a blanket, the pack soon becomes hot ; how- 
ever, in children it usually suffices. The external use of cold is so 
decisive that in private practise the physician should insist that every 
obstacle be surmounted. An easy method of using cold is that devised 
by Wood, M. D. An ordinary cot should be placed at the side of the 
bed, half open, and covered with a rubber sheet so arranged that the 
upper end of the sheet goes over the headboard, while the lower end 
forms a sort of trough at the foot of the cot, the head of which is slightly 
elevated. The patient, being wrapped in a wet sheet, can be readily 
slid from the bed to the cot, and then by means of a large sponge, the 
patient can be soused continuously with cold water, which lies about 
the patient, and, as it accumulates, runs off at the bottom of the cot 
into a tub. The rubber sheet can be placed under the patient in bed 
when there is no cot at hand ; a trough can be made of it, and the patient 
soused with water as required. An ordinary sprinkler answers well 
when there is no large sponge at hand, which is often the case in the 
country. 

The Cold Pack. — A blanket is spread evenly over a couch or bed ; 
a coarse wet sheet may be laid smoothly over the blanket, folded once. 
'The patient is now lifted onto the bed thus prepared, and quickly 
wrapped in the wet sheet, keeping the sheet smooth as possible over every 
part of the body except the head. If the extremities feel cold before 
the packing, they must be warmed by friction, or else the extremities 
below the thighs should not be included in the packing. 

As soon as the child is wrapped up smoothly in the cold wet sheet, 
the nurse may fold the blanket over the patient in the same manner, 
first drawing over and tucking one side smoothly under, then the other 
side, seeing the chin is free, and that the blanket is folded evenly, but 
without tension at the neck. Finally, the long end is drawn down and 
folded smoothly under the feet. Three or four thicknesses of the wet 
sheet spread upon the blanket are necessary to reduce the temperature 
effectively. Repeated packings may be necessary to reduce the tem- 
perature ; in such cases there may have to be two cots, or one cot and a 
bed, and the patient should be lifted from one to the other. When the 
temperature does not rise above normal, or when shivering takes place, 
the packing must not again be renewed. 

During the packing the pulse is felt at the carotid artery, or tem- 
poral artery, and the temperature taken by the mouth. 

The patient is allowed to remain in the last pack from half an hour 
to an hour ; at the expiration of this time the skin generally becomes 
pleasantly warm, and in many cases outbreaks of perspiration take place. 

The Cold or Gradually-Cooled Baths. — The gradually-cooled bath 
is generally employed. The quantity of water must be enough to 
immerse the body of the patient ; the tub should be portable and stand 
at the bedside ; and during the bath the skin should be gently rubbed. 
The temperature of the water should be about 100 degrees Fahrenheit, 
even higher than this at the first bath. As the patient becomes accus- 



468 Enteric or Typhoid Fever. 

tomed to the bath, it is gradually cooled down by the addition of cold 
water to 80 degrees Fahrenheit or lower. Under no circumstances 
should it be cooled helow 75 degrees Fahrenheit. The average dura- 
tion of the bath is live minutes ; but if shivering or great uneasiness 
should occur, the patient must be lifted into bed, placed upon a sheet 
previously made ready, and wiped dry, with brisk rubbing of the 
extremities and back; the moist sheet is then removed. The patient 
is covered up, and some hot soup, or wine, or brandy and water admin- 
istered. The temperature is not always immediately reduced, but, as 
measured in the rectum, usually falls within an hour from 1% to 4 
degrees. In the course of some hours it rises again, and the bath is 
then repeated. If cold baths are not well borne, good results in low- 
ering the temperature often follow prolonged lukewarm baths. Some- 
times it becomes necessary to repeat the bath once in the course of 
twenty-four hours. A patient who is sleeping quietly, even though 
his temperature be high, should not be roused and immediately placed 
in the bath. 

It must be remembered that when young children are treated by 
this method, the temperature of the bath at the beginning should be 
warm, and the blanket in which the little patient is gradually lowered 
into the water, spread over the bath-tub. 

^Tot only is the child's temperature lowered by this means, but 
also a very favorable influence is exerted upon the state of the nervous 
system. The intellect clears up, the clulness diminishes. 

Gold Affusion. — While the patient is in the tub, cold water 60 
degrees Fahrenheit is thrown by means of a sponge over his head, 
face, neck, shoulders, and chest. This is repeated once or twice just 
before removing the patient from the bath. It is done more for the sake 
of the good effect upon the nervous system in cases of great stupor and 
evidences of serious nervous derangement, than merely as a means of 
reducing high temperature. 

Ice-Water Enemata. — Rectal injection, carefully administered, is 
recommended for lowering the temperature. In enteric fever the 
quantity of cold water should not exceed three ounces. 

The face and head of the patient must always be well bathed with 
cold water just before and during the application of cold to the gen- 
eral surface of the body. The occurrence of a chill or rigor may be 
delayed by more or less vigorous rubbing or chafing of the body. 

The reduction of the temperature by one or two degrees often fol- 
lows the administration of a tepid bath of 85 degrees to 95 degrees 
Fahrenheit of a duration of from five to ten minutes. 

Contra-indications to the use of the bath are marked general debil- 
ity, feebleness of the heart action, coolness of the surface and extremi- 
ties, and intestinal hemorrhage. 

Chest complications, even when severe, do not as a rule neces- 
sarily contra-indicate the very cautious employment of antipyretic 
treatment when the temperature becomes dangerously high. 



Enteric or Typhoid Fever. 469 

Other conrplicated sequels are to be treated in accordance with 
general therapeutic indications, and are directed bj the family physi- 
cian. 

The expectant treatment, in many of the milder cases, does well 
without any medication whatever. Rest in bed, careful nursing, and 
a well-regulated dietary, constitute all that is necessary for the proper 
management of the case. With moderate fever, absent or insignificant 
chest symptoms, a good heart, and little or no evidence of serious 
intestinal lesions, there is no need for the administration of much medi- 
cine. In such cases there is often a slight tendency to constipation. 
In all cases, at most, we may commence our treatment advantageously 
with a mild purgative dose of calomel; from one-tenth of a grain to 
one-twelfth of a grain, according to the age of the child, may be given 
every two hours until four doses have been administered (J. Wyeth's 
Triturates of Calomel and Bicarbonate of Soda from one-tenth to one- 
twelfth grain). If the bowels do not move in six or eight hours after 
the last dose has been administered, an enema of warm flaxseed tea, 
or of warm water with a little salt, or of warm water with castile 
soap-suds, may be used ; from one-half to a pint of water is usually 
sufficient to move the bowels. We have had satisfactory results with 
a teaspoonful of glycerine in a teacup of warm water used as an enema 
to move the bowels. Also a ninety per cent glycerine suppository 
inserted into the rectum has acted promptly. These measures to 
secure action of the bowels do not require repetition oftener than once 
a week. The calomel, however, may be repeated from time to time 
until the end of the first or middle of the second week of the attack 
only. 

The so-called rational plan of treatment, like the expectant plan, 
makes no attempt to shorten the duration of the attack, or to modify 
its course as determined by the intensity of the infection and the reac- 
tion of the organism to that infection. In the absence of serious 
symptoms or complications, it is practically the same as the expectant 
plan. 

When there is persistent nausea or vomiting in typhoid fever, 
the diet should consist exclusively of two to three parts milk to one 
part of lime-water, or of milk and carbonic-acid water ; and if these 
fail, animal broths may be given. In very severe cases no stronger 
food than wine whey, barley water, or beaten-up whites of eggs strained 
through thin muslin and mixed with double the amount of water (the 
whites of the eggs whipped only a little, so they will strain easily) , may 
be borne, and sometimes it may be necessary to withdraw for a time 
all food by the mouth, the patient being sustained by thoroughly pep- 
tonized nutrient injections. 

The drugs which are useful are cocaine (dose, from one-tenth to 
one-quarter of a grain for adults, for a child according to the age), 
which may be administered from ten to twenty minutes before food 
is given; bismuth, with one-twentieth of a grain of calomel or without 



470 Enteric or Typhoid Fever. 

calomel, according to the individual case, given when the stomach is 
empty; and nitrate of silver (one-eighth of a grain to an adult). A 
sinapism or blister to the pit of the stomach is sometimes of great 
service in persistent nausea. 

Unless the diarrhea amounts to more than three passages a day, 
is should rarely be interfered with. If the patient fails to have a 
loose stool every day, especially if there is a tendency to excessive 
tympanitis, sweet-oil may be given, or, what is better, sweet-oil in a lit- 
tle flaxseed tea, small but frequent injections, till the bowels move. 
For the control of excessive diarrhea, paregoric and subnitrate of 
bismuth or opium suppositories may be employed. The following 
mixture is especially valuable : — 

I£: Bismuth subcarbonitis 5iij 

Acidi earbolici gr. x 

Cam ph. tr. opii giij 

Mucil acacise ad Jvi 

Misce. Shake thoroughly; give a half-teaspoonful to a child ten 
years old every two or three hours, and smaller doses for younger 
children. 

Logwood mixtures are sometimes of service: — 

I£: Acidi su]purici aromatici f3ij 

Ext. hsematoxyli 3iii 

Syr. zingiberis fliss 

Misce et adde. 

Tr. opii camphorated fiss 

Sig. Dessert-spoonful in water, to a teaspoonful according to the 
age. 

When the stools are large and very thin, bismuth subnitrate may 
be given freely in large doses (gr. v-xx) every four or six hours. If 
necessary, may add to this opium in doses proportionate to the age 
of the patient (gr. T fo-4V or Dover's powder gr. ^V _ i- Equally 
satisfactory is the combination of minute doses of calomel (gr. ¥ V~rV) 
with Dover's powder in doses suitable to the age of the patient. 

The oil of turpentine, administered in linseed oil by the rectum, 
is effective for the treatment of the intestinal ulceration. It should 
be given by the mouth in capsules or in starch emulsion; the dose for 
an adult of the oil of turpentine is from five to ten minims. If it 
be given in starch, a fresh amount should be prepared every morning. 
Give the remedy three times in twenty-four hours. The writer usually 
gives from three to five minims in one tablespoonful of starch emul- 
sion to a child from five to ten years of age, between regular meal- 
times, three times in twenty-four hours. A flannel cloth large enough 



Enteric or Typhoid Fever. 471 

to cover the abdomen is dipped in the oil of turpentine, and laid over 
the bowels, and over this a piece of oil silk, confined with a light 
bandage. To administer the turpentine per rectum when it disagrees 
with the stomach, the bowels are first moved off with warm flaxseed 
tea with a little glycerine added; then a soft rubber tube is passed 
up through the rectum about six inches or more, and about one table- 
spoonful of linseed oil is administered, well mixed with ten to twenty 
drops of the oil of turpentine. Always have a sufficient quantity to 
allow of a little being left in the tube, which has been attached to a 
fountain or a cylinder syringe. This may be repeated three times 
in twenty-four hours; and when carefully administered, it is a harm- 
less remedy. Peyer's patch will heal from the administration when 
other remedies fail. Thymol is highly recommended in doses of from 
two to five grains for adults, less for children; this is a substitute for 
turpentine. Some physicians recommend solol, iodine, and chlorine for 
the purpose of destroying the typhoid bacillus ; but by other physicians 
it is said that there is no sufficient reason for believing that the course 
of typhoid fever can be modified by any of these agents, though some 
of them may act favorably by their local effect upon the alimentary 
canal. In choosing a remedy the physician should see that the drug 
is incapable of doing any harm. 

In all cases of abdominal symptoms and tympany counter-irrita- 
tion over the whole surface of the abdomen is recommended. Spices, 
plaster, or hot cloth wrung out of spice water may be used ; but no doubt 
the turpentine stupes following warm fomentations of the bowels is 
the best counter-irritant. The fomentation may be given by means of 
a hot flannel wrung out and laid over the bowels for half an hour; 
then put on the turpentine stupe, as already directed. 

When intestinal hemorrhage occurs, opium should be freely used 
for an adult (less for children), to secure quiet and prevent alarm. 
Absolute rest must be enjoined, and in severe cases the patient should 
not be disturbed with the bed-pan, but slip a piece of oilcloth, or, 
better still, a rubber sheet, underneath the water, and let the dejecta 
pass into a sheet which has been placed over the rubber cloth. In all 
cases a folded sheet, called a "draw-cloth," should be kept smoothly 
under the patient for the purpose of easy handling by rolling the 
patient a little, so that the genitals can be easily cleansed. Ice-bag 
filled with ice, wrapped with a flannel, should be applied over the 
surface of the abdomen, and the food should be restricted with severity 
proportionate to the gravity of the hemorrhage. In bad cases whites 
of eggs strained and animal broth or essences should alone be given. 
The best styptic, according to Wood's experience, is Monsel's salts (not 
solution), which should be given in double capsules in doses of one-half 
to one grain, at intervals of from one to four hours. Tannic acid is 
used by some physicians. Oil of erigeron, in doses of fifteen to twenty 
drops every two or three hours, it is said, may sometimes be advan- 
tageously substituted. Extract of ergot (ten grains in capsules) may 



472 , Enteric or Typhoid Fever. 

be of great service, alternated with Monsel's salts in such a way that 
the patient gets one dose every two or three hours. In sudden bad 
cases of hemorrhage extract of ergot may be given hypodermically. 

Collapse occurring from intestinal hemorrhage is met with the 
usual remedies and transfusion, or the normal saline solution (one-half 
per cent) may be injected slowly into a vein or buttock, the greatest 
care being exercised to see that the injected liquid and the apparatus 
used have been absolutely sterilized by heat. A large quantity of the 
solution can thus be absorbed. Usually one pint or more is used at 
a time. Moreover, the injections (Venus) can be repeated until the 
result is secured. Before injecting the salt solution, the part is to be 
washed with carbolized solution, then the parts sprayed with ethyl 
chloride Bengue to deaden the skin, so that the passing of the instru- 
ment will not give any pain. 

Peritonitis in typhoid fever is usually caused from perforation, 
and ends fatally when not localized in the neighborhood of the appen- 
dix. The best treatment is in the use of opium up to continuous mild 
narcotism and in abstinence from food. When perforation can be 
diagnosed, laparotomy is recommended. Cases do occasionally recover 
from perforation without surgical aid. In 1891, Fitz collected twenty- 
seven recorded cases of recovery from peritonitis, three after opera- 
tion, seventen after resolution, and nine after the spontaneous dis- 
charge of pus. According to Osier, the corrected statistics up to 1895, 
excluding doubtful cases, were twenty-four laparotomies with six recov- 
eries. 

When headache in typhoid fever is severe enough to require treat- 
ment, phenacetine or antipyrine may be used very carefully, in doses 
moderate for adults, very small for children. Under no circumstances 
should they be actually pushed. A cold cloth wrung out and laid 
over the forehead often relieves headache. It is better to rely on 
opium for the relief of the pain in the head, if it be otherwise uncon- 
trollable. Should there be an epileptiform convulsion, a blister may 
be applied over the back of the neck, or on the back of the scalp after 
shearing it. The blister should not be allowed to remain on more 
than half an hour. The parts may be dressed with a corn-starch 
poultice with plenty of sweet-oil spread over the poultice. Keep the 
poultice thus applied till the blister heals. Two poultices a day are 
sufficient to keep the patient comfortable. Remember that old linen 
cloth or an old handkerchief, etc., is best to use for the poultice. For 
the relief of insomnia, opium, trional, or sulphonal may be employed. 
Chloral acts most admirably when there is no exhaustion, but it has 
to be given with great caution. In the excessive adynamia of typhoid 
fever, strychnine (one-thirtieth to one-fiftieth of a grain) proportionate 
to the age of the patient is a most useful remedy. In severe cases it 
should be given hypodermically at intervals of four hours, or, better, 
alternately with cocaine (one-sixth to one-third of a grain) at inter- 
vals of six hours (three hours between doses), according to the age 



Enteric or Typhoid Fever. 473 

of the patient. Digitalis and stropkantlms are sometimes useful for 
sustaining the heart. 

In the crisis of typhoid fever, when failure of vital power shows 
itself in simple collapse, in a furious delirium, in a high temperature 
which can not be controlled except for the moment by the application 
of colds, or in case of coma vigil, musk is said to be a valuable remedy. 
It should be given by the rectum in doses of fifteen grains every four 
or six hours, in two ounces of starch water with a little laudanum. Of 
course children require less amount of musk, but given in the same 
manner. 

Pulmonic congestion in typhoid fever calls for further stimula- 
tion of the circulation, as it is largely due to cardiac and vasomotor 
weakness; alcohol, strychnine^ cocaine, and digitalis should be given 
alternately or in combination. Large doses of ergot extract (ten 
grains given every two or three hours for adults) may be used for 
vasomotor stimulation, while oil of turpentine or of eucalyptus and 
terebene are the best expectorants. Turpentine stupes should be 
freely used. 

THE MANAGEMENT OF THE PATIEXT DURING CONVALESCENCE. 

During the early days of convalescence the temperature remains 
labile, and abrupt recrudescences of the fever are apt to arise from 
very slight causes. It is therefore important that the patient be cared 
for assiduously for some time after convalescence is complete. For 
at least one or two weeks the temperature should be taken morning 
and evening, and during this time the diet is to be restricted to milk, 
soft-boiled eggs (better taken raw), custard, animal broths, or chicken 
jellies, and the lighter farinaceous foods. At the end of a week an 
adult may take wholesome, easily-digested solid food, including meat, 
but not fried; but the effect of such changes of diet upon the tempera- 
ture and general condition of the patient is to be carefully watched. 
Quinine, iron, and cod-liver oil may be administered, if convalescence 
be tardy and anaemia persists. 



CHAPTER XXIX. 
TYPHUS FEVER. 

Definition. — Typhus fever is an acute, contagious febrile disease, 
characterized by an eruption on the skin of ill-defined, brownish-red 
spots, great prostration, high fever, and profound nervous disturbances. 
The eruption usually appears from the third to the fifth day, and often 
becomes petechial. 

History. — On this point there is very little to be said. The dis- 
ease is not mentioned by any physician of ancient times ; but it has 
been asserted that the great plague of Athens was typhus. It was 
first clearly described by Fraeastorius in the fifteenth century; but 
from this time on it was confounded with other diseases until, about 
18i6, Jenner showed it to be quite distinct from enteric fever, and 
consequently from everything else. The last great epidemic of typhus 
was that which affected the Erench troops during the Crimean War. 

Etiology. — Typhus does not arise primarily among children, but 
when it appears among adults, children of all ages take it. Its cause 
is unknown. It has been confidently asserted that it arises from desti- 
tution, overcrowding, and unsanitary conditions. It is endemic in Ire- 
land, Bohemia, the valley of the Danube, and certain other portions 
of the world. It has been closely connected with famine, overcrowd- 
ing, and the miseries of extreme poverty ; and it has especially abounded 
in jails, in immigrant ships, and during sieges; hence the names 
prison-fever, ship-fever, camp-fever. It is extremely contagious, the 
danger increasing enormously when cases are collected in hospitals, 
under which circumstances the nurses and medical attendants are 
liable to suffer. It may be communicated through the wearing apparel, 
the bedclothing, etc., and persons not suffering themselves may become 
sources of infection. Epidemics may also arise from bales of rags 
or other similar material which has been gathered in affected dis- 
tricts. It is thought probable that the poison escapes from the body 
through all possible avenues, although on this point there is little 
definite knowledge. 

Epidemics are more common and more severe in winter than in 
summer, due, in all probability, to the overcrowding and lack of venti- 
lation which prevail in cold weather. A patient suffering from this 
disease should be isolated from the rest of the family and abundantly 
supplied with fresh air, while the utmost precaution should be taken 
in the disinfecting of the discharges, of bed linen, and of the clothing, 
the same as has been advised in typhoid cases. (See Typhoid Fever.) 

(474) 



Typhus Fever. 475 

It is said that the contagion does not extend far beyond the patient, 
and therefore, with due regard to cubic space and ventilation, others can 
be protected by isolation; but when they are "pent up" and about, they 
run the risk of contracting the disease by direct communication with 
the typhus cases. 

Symptoms. — These in children are not usually well marked, 
although cases are reported presenting all the severity so common 
among adults. 

The period of incubation of typhus fever is usually put down as 
twelve days, but it may be much longer or much shorter. During this 
stage the symptoms are very slight. The disease in most cases is said 
to commence suddenly with a chill, followed by an immediate rise of 
temperature, which may reach 105 degrees or 106 degrees Fahrenheit 
on the second day. During the next ten or twelve days there is no 
remission of the fever, but the evening temperatures are from two to 
four degrees higher than those of the morning. At the end of the 
tenth or twelfth day the temperature usually falls, not with the abso- 
lute abruptness of a pneumonic crisis, but in the course of two or three 
days. In fatal cases it is common for death to be preceded by a sud- 
den rise of temperature to a great height, even 108 degrees Fahrenheit. 

The general symptoms of typhus fever develop almost as rapidly 
as the fever; the pulse is full and quick but soft, and only in rare 
instances dicrotic; from the first the pulse lessens in power more and 
more as the disease progresses. The typhus face, even in the earliest 
stage, is characterized by the dark reddish, almost cyanotic tint, not only 
of the face itself, but also of the conjunctiva, and by its heavy, stupor- 
ous expression. The tongue, which is whitish and moist, soon becomes 
dark, and assumes a brownish color, corresponding with the ever- 
increasing sordes about the teeth. 

A peculiar odor resembling somewhat that of putrefaction, is given 
forth from the skin, with the breath, or with excretions. The violent 
headache, and the atrocious pains in the back and in the limbs, which 
mark the outset of the disease, may continue until they are lost in 
a stupor, which is commonly broken by a low, muttering delirium. 

The mental state varies greatly in different cases, or sometimes 
from day to day in a single case. 

A wild, raging mania may break forth ; or an hallucinatory delir- 
ium, with a never-ending, rapid succession of visions, with extreme 
agitation and emotional excitement, may closely simulate delirium 
tremens and give rise to attempts at escape, to assaults upon the nurse 
or care-takers, who are mistaken for tormenting demons, and even to 
suicide as a means of escape from haunting melancholia. Hours will 
be spent in a wild harangue to an imaginary audience upon a religious 
or other topic. Usually on the third or fourth day, although some- 
times delayed until the eighth day, the eruption appears upon the 
front of the chest and abdomen, and rapidly spreads, so that in two or 
three days it covers the whole body. As the disease progresses, the 



476 Typhus Fever. 

rash becomes more and more distinctly hemorrhagic, until it takes 
the form of small, irregular, petechial patches. 

During the second week of the disease there are extreme pros- 
tration, a rapid and feeble pulse, subsultus tendinum, carphologia, or 
picking of the bedclothes, and, it may be, a tendency to sloughing of 
the buttock, heels, and other parts of the body exposed to pressure. 
Almost invariably bronchial irritation and pulmonic congestion are 
present in the beginning of a typhus fever, and not rarely they increase 
until they become a serious element of danger. 

Pronounced abdominal symptoms are rare in typhus fever, and 
when they do occur are to be looked upon rather as accidental than as 
characteristic. The anorexia is complete, but not active disgust for 
food. There is no meteorism and no abdominal tenderness ; ordinarily 
the bowels are constipated, the stools being normal in color and con- 
sistency. There are reported cases of diarrhea occurring occasionally. 
If perchance the stools are liquid, they are usually dark-greenish, never 
being of the yellow-ochre color of the typhoid stool. The spleen may 
or may not be enlarged. The urine is scanty, and may in somewhat 
exceptional cases be albuminous, but nephritis is rare. There is the 
usual febrile increase of urea and uric acid, with lessening of the 
chlorides. 

Typhus fever is a disease much more uniform and self -consistent in 
its course than is typhoid fever, varying chiefly in intensity. It may be 
so slight that diagnosis is uncertain; it may be so malignant that the 
patient dies in profound exhaustion as early as the second or third 
day, covered with petechias from blood destruction. 

The convalescence from typhus fever is usually rapid and free 
from complications, though it may be interrupted by septic purulent 
inflammations, such as parotitis and abscesses. 

Diagnosis. — In children it should be remembered that although 
they contract typhus fever, it is not usually found among them except 
in association with adults ; so that when a case is met with in a child, 
a well-marked case or cases will probably be found among its adult 
relations or neighbors. It should also be remembered that typhus fever 
is usually epidemic, either in the district, the town, the village, the 
street, or the house ; so that if one case is found, there will probably 
be others not far off. The diseases with which it is most frequently 
confounded in the case of adults are pneumonia and chronic kidney 
trouble. The eruption of the typhus is the most characteristic symp- 
tom, but it is unfortunate for the purpose of diagnosis in children that 
it is rarely well marked. In the case of these, therefore, help must 
be looked for in the general surroundings of the patient. The history 
of the case should be carefully considered, and the presence of other 
cases in the family or neighborhood should be inquired after. 

Next in importance to these considerations is the general aspect 
of the child. The expression is dull and heavy, the eyes have an 
injected appearance, and generally it is somewhat drowsy. With these 



Typhus Fever. 477 

symptoms there are no local changes to account for the ill-defined 
fever in the case of a child whose adult relations or immediate neigh- 
bors were or had been affected by typhus symptoms or physical signs, — 
no chest or abdominal symptoms, no acute pains in the head, as in 
meningitis, even though it complains of headache. If with these 
symptoms there is faint mottling of the skin, particularly of the 
wrist and subclavicular regions (care having been taken to eliminate 
ib flea bites"), there can be but little doubt that the disease is typhus. 
The diagnosis may be made from attention to the following consider- 
ations. In pure hemorrhagic smallpox the spots are very large, often 
like spots which may be made by throwing ink from a pen on white 
blotting-paper, and they exist in large numbers closely packed over 
the lower abdomen ; in typhus they are minute, about one-sixteenth to 
one-twelfth of an inch in diameter, and they are distributed all over 
the body. 

In hemorrhagic smallpox, the petechial and purpuric spots are 
almost invariably accompanied by blood-clots in the conjunctivae, and 
sometimes by large patches exactly like the bruises produced by blows ; 
in typhus fever there is nothing of the kind. In hemorrhagic small- 
pox the eruption is accompanied by hemorrhage from one or all, usually 
several, of the mucous surfaces ; in typhus there is nothing like this. In 
hemorrhagic smallpox these eruptions are well out on the third or 
at least on the fourth day; in typhus, the eruption does not, as a 
rule, begin to come out until about the fifth day, and is not well 
out till about the seventh clay, and does not become petechial till 
about the tenth day, and in children it is rarely petechial because of 
the mildness of the disease and of the occurrence of the crisis at or 
before that day. 

Measles might in some cases give rise to difficulty, for in these 
the eye is suffused and injected, and the expression drowsy; but the 
eruption is most abundant and most marked on the face, whereas in 
typhus, the eruption is rarely on .the face, and Avhen it is, it is but 
slightly marked and never characteristic. 

Unfavorable signs are extensive congestion and inflammation of 
the lungs, bronchitis, pleurisy, nephritis, laryngitis, and diphtheria ; 
but in children under ten these complications are very rare. 

Treatment. — There is no specific treatment of typhus fever. The 
management of the case is about the same in princple as that which 
has been discussed in typhoid fever. Typhus fever, for the most part, 
is so mild in children that active treatment is rarely required. The 
patient should have good nursing and a well-ventilated room, the 
temperature of which should be kept about 50 degrees Fahrenheit 
during the acute stage. The child should be fed upon milk, beef tea, 
chicken broth, bread steeped in the beef tea, and raw eggs, of which 
he should have as much as he chooses to take. The mouth should 
be kept scrupulously clean by washing with a soft tooth-brush or a 
soft mop as often as may be necessary. Give the patient all the cold 



478 Typhus Fever. 

water that is desired ; ice-water is very agreeable. A tepid bath should 
be given daily, and the clothing changed, also the bed linen. No drug 
beyond a dose of castor-oil will be required. 

Giving medicine so as to cause the patient as little disgust as 
possible is no slight art, and one that it is worth any trouble to gain. 
Tn the first place, the glass or vessel in which it is given must be 
thoroughly clean, not having been used to give a previous dose, and 
remaining unwashed, as is so often the case. Never pour the medi- 
cine out in sight of the patient if it is in the least disagreeable to 
him; and if the child is to take anything after the medicine, give it 
instantly after the medicine, so that the taste of medicine will not 
last long, and thus prevent disgust as far as possible. Castor-oil should 
be given warm; put orange juice in the glass first, then the oil, then 
more orange juice. The patient must be encouraged to open his mouth 
and take it boldly, then let him take a little piece of orange, and suck 
it till the taste of the oil has disappeared. It may be given in diluted 
brandy or lemon juice in a similar manner. Bed-sores must be 
guarded against by keeping the sheets and clothing smooth. Wrinkled 
clothing will provoke bed-sores. To avoid this, some spirit lotion 
should be employed and a water-bed supplied. When there is much 
restlessness, sponging with cold water will be found very quieting. 
To favor sleep, the patient should be kept quiet ; and if necessary to 
procure it by artificial means, a warm bath followed by a dose of port 
wine may be given, and generally opium should be avoided. The 
bladder should be examined, as retention might arise. When the tem- 
perature has fallen, the child may return at once to his ordinary diet. 
Antipyretics, such as the cold bath, quinine, antipyrine, and anti- 
febrine, will rarely be required in the case of children, because of the 
mildness of the disease. In adults more active measures are required 
from the very beginning than are called for in children. 



CHAPTER XXX. 
RELAPSING FEVER. 

Definition. — This is a contagious febrile disease, produced by the 
presence in the blood of the spirillum (spirochaeta) of Obermeier, and 
characterized by a succession of febrile paroxysms and remissions, each 
of about six days' duration and recurring from two to four times. 

Etiology. — The immediate cause of relapsing fever appears to be 
the spirillum which was discovered in 1873 by Obermeier. The con- 
tagion is capable of producing the disorder without any predisposing 
causes. The contagium may be communicated directly from person to 
person or may be carried in various fomites or in anything containing 
heat, as in woolen goods, feathers, etc. It seems to be rather less acute 
and enduring than the contagia of typhus and scarlet fever. Neither 
age, nor sex, nor race, nor season has distinct etiological influence. In 
India relapsing fever seems to be almost endemic, according to statistics. 

Morbid Anatomy. — Hyperplasia of the bone-marrow and of the 
spleen, with cloudy swelling in the liver, kidneys, and heart, granu- 
lar degeneration, with the presence of infarction in the various organs, 
are lesions which have been noted after death from relapsing fever ; but 
they can not be considered especially characteristic in any way. 

Symptomatology. — Relapsing fever is a disease which affects 
both sexes and all ages, except, perhaps, that the infant under one 
year of age is rarely affected with it. 

The period of incubation is usually from five to eight days, but 
in some cases it has appeared to be only about twenty hours. The 
attack begins abruptly, with a chill, general aching pains, often with 
vomiting and vertigo, and sometimes with convulsions. In children, 
however, as a rule the symptoms are less marked, and not infrequently 
the disease is of the abortive type; that is, there exists a tendency to 
run a shorter and milder course than in adults. When an abrupt chill 
or rigor comes on, the temperature may run up to 105 degrees to 
106 degrees Fahrenheit, with a quick, rapid pulse, sharp pain in the 
head, darting pains in the limbs and loins, no desire for food, and 
great thirst ; there is vomiting and anorexia. In severe cases there 
is violent headache, insomnia, and in some cases delirium. The 
enlargement of the spleen is rapid and often great; the liver is simi- 
larly affected, but not to so great an extent. 

Typical cases are steadily maintained until the fifth or sixth 
day, when there is an abrupt defervescence, accompanied by a 
profuse sweating, or sometimes diarrhea. This crisis is sometimes 
deferred for ten or more days, and sometimes develops as early as the 
third day. In persons of feeble constitution, subnormal temperature 

(479) 



480 Relapsing Fever. 

and collapse are not rare. Convalescence is immediate, the patient 
getting up at once. On the fourteenth day there is a return of the 
chill, with abrupt fever and other phenomena of the paroxysm. The 
second paroxysm is, as a rule, shorter than the first, and by a series 
of relapses the patient may be left profoundly exhausted. We often 
see jaundice, epistaxis, hypostatic congestion of the lungs, nephritis, 
acute enlargement of the spleen, sometimes ending in abscess. 

Diagnosis. — The principal points in the diagnosis of the disease 
are : First, the spirillum, which is to be found in the blood by micro- 
scopic examination, provided Obermeier and others are correct. Sec- 
ond, the abrupt and rapid rise of temperature. Within twenty-four 
hours the temperature reaches 103 degrees to 105 degrees and even 106 
degrees Fahrenheit in severe cases. On the fifth or seventh day it falls 
precipitately to a subnormal point, where it remains until about the four- 
teenth day, when it abruptly rises again, which is the commencement 
of the paroxysm. 

Differential Diagnosis, from the Eruptive Fever. — There are no 
specific eruptions in relapsing fever and no abdominal symptoms such 
as are found in typhoid fever; from typhus fever it is distinguished 
by muscular pains; the remarkable enlargement of the spleen, and 
the peculiar temperature. 

Prognosis. — In youth, relapsing fever, like typhus, is generally 
of a mild type ; hence the prognosis is more favorable than in adult 
cases. 

Treatment. — There is no known way of aborting a paroxysm of 
relapsing fever or of preventing its recurrence. Quinine does not have 
any special influence. A plentiful supply of air should be in the room, 
but no draught should be allowed; otherwise there may be danger of 
pneumonia and other complications as the result of exposure. 

Absolute cleanliness of the room and the patient should be looked 
to. Isolation of the patient and rigid disinfection of the clothing are 
necessary to prevent the spread of the disease. The patient must be con- 
fined in bed, not only during the paroxysm, but especially during the 
intermission, and be freely fed with milk broths and other light food ; 
but the stomach should not be overloaded or crowded. 

The body of the patient should be washed with some disinfect- 
ing solution. Take carbolic acid one drachm to a pint of water ; wash 
the patient first with warm water with soda bicarbonate rubbed all 
over the body, then rinsed off ; then sponge with carbolized water. This 
renders inert the poisonous exhalations from the body. Good, old- 
fashioned lye soap to cleanse the body with is very effective. The bed- 
clothing as well as the patient's clothing should be changed daily and 
boiled when washed. (See Typhoid Fever, Asepsis of.) 

Early in the disease, as is agreed among authors, very little medi- 
cine is required. A laxative may be administered, or an alterative 
and laxative combined, as hydrarg-chloridum mite et sodae ( 1 to 2 grains 
for an adult), followed in eight hours with a saline laxative, such as 



Relapsing Fever. 481 

Epsom or Rochelle salts. Where vomiting is present, small doses of 
calomel and opium combined will generally allay it, or the following 
mixture has proved beneficial in the writer's hands : — 

\]l: Iodine gr. xv 

Acid carbolic gr. viii 

Aquae menth pip 

Mucil acise, aa . . . , 3J 

M. et sig. : For adults. Put fifteen drops in three tablespoonfuls 
of ice-water; give of this a teaspoonful every fifteen minutes or every 
half hour, until vomiting is controlled. 

For headache, apply an ice-cold cloth to the head, or an ice-bag 
or bladder. At times a hot mustard foot-bath gives relief. Leeching 
and dry cupping are often of great service. For pains in the back, 
opium, administered hypodermically or by the mouth, should be used 
pro re nata. Salicylates are said to be injurious. Chloral, admin- 
istered with one or more heart tonics for sleeplessness, is considered 
the most efficient, but it must be used with great care. Digitalis, 
strophanthus, fluid extract of cactus grandiflora, citrate of caffeine or 
caffeine — either of these that is suitable to the general condition of the 
patient may be given with the chloral. Alcohol and other stimulants 
are to be freely given when there is much prostration. The hyper- 
thermia is best met with cold baths. Turpentine stupes, stimulating 
frictions, and dry cupping over heart and lungs are recommended. All 
depressing medicines should be avoided. 

Jaundice should be treated by the milder remedies- usually 
employed in catarrhal jaundice; the phosphate and sulphate of sodium 
take precedence among the remedies for jaundice in children. 
Harley has extolled the virtues of Glauber's salt, sulphate sodium. 
These salts may be given together, and seem to be more efficient com- 
bined than when given separately. 

Muscular pain is relieved considerably by chloroform liniment : — 

Ijfc: Chloroform Jij 

Oil peppermint 3ij 

Oil sassafras 3jss 

Tr. arnica |i v 

Spt. etherii nit, ad gviii 

M. et sig. (Liniment.) 

Apply when necessary, or twice or three times in twenty-four 
hours, rubbing thoroughly over seat of pain. 

During convalescence, caution and rest must be enjoined to avoid 
heart failure. 

The treatment for the convalescent stage consists in rest, tonics, 
such as cinchona, iron, and malt extract, and alcoholics if required. 
Later on, a change of air and surroundings may be advantageous. 

Pneumonia, should it exist, may be treated the same as typhoid 
pneumonia. 

Abscesses should be treated on general principles. 

31 



CHAPTER XXXI. 
CEREBROSPINAL MENINGITIS (SPOTTED EEVER). 

Definition. — This is a febrile disorder, "probably a microbic dis- 
ease/' occurring in widespread local epidemics. It is chiefly mani- 
fested by the occurrence of cerebro-spinal meningitis. The prominent 
symptoms are such as meningitis gives rise to, namely, fever, headache^ 
tonic contraction of the muscles of the neck, spine, hyperesthesia, 
and neuralgic pains in the trunks and extremities. It is non-contagious, 
or, if contagious, it is thought to be to a very low degree ; and, like most 
of the microbic diseases, its victims are chiefly the young. It begins 
abruptly or without a premonitory stage, and is often speedily fatal 
from intense hypersemia of the nerve centers, or the severity of the 
cerebro-spinal meningitis. In other cases, after weeks or months of 
suffering and progressive loss of flesh and strength, death occurs in 
a state of extreme prostration ; and in those who recover, convalescence 
is protracted and slow. 

Etiology. — It is thought that the disease may be produced by a 
micro-organism. This is generally believed; but it is one of the most 
mysterious diseases. Its origin has not been traced to overcrowd- 
ing, or to the accumulation of filth, or to any ordinary causes of febrile 
disease. Some writers, however, claim that it might be favored by 
overcrowding of individuals, so that it is especially prone to appear 
amid the misery and poverty of large tenement houses in cities, and 
it is said that it has been severe among soldiers in garrison towns. It 
does not spread from one person to another, and the attendants upon 
the sick are very rarely affected. It is not known to be carried in 
fomites. Long-continued, excessive labor, whether mental or bodily, 
seems to predispose to the attacks. 

Dr. A. Erankel and other European microscopists have carefully 
examined the bacteria found in the blood and tissues of those affected 
by it. At a meeting of the Berlin Medical Society, held February 12, 
1885, Herr Ley den showed under a microscope specimens of micro- 
cocci found in a case of cerebro-spinal fever. Dr. V. O. Pushkareff, 
connected with one of the barrack infirmaries of St. Petersburg, stated 
that in five cases of croupous pneumonia in which cerebro-spinal menin- 
gitis occurred as a complication, he discovered in the pus taken from 
the cerebral meninges swarms of micrococci, whose appearance under 
the microscope seemed identical with that of Eriedlander's pneu- 
mococcus. 1 They were either isolated or in groups of two, seldom four. 



1 Deutsch. Med. Wochenscher, April 4, 1883. 
(482) 



Cerebro-Spinal Meningitis. 483 

having distinct capsules, and they were absent from the fluid taken from 
the meninges in simple pneumonia. Pushkareff was able to cultivate 
the micrococcus taken from meningeal pus, and the cultivated microbes, 
like their parents, presented an appearance identical with that of the 
pneumococcus. 1 Moreover, Ebertho', in a case of meningitis following 
pneumonia, believes that he found the same micrococcus in the lungs 
and in the liquid taken from the inflamed pia mater. Frankell also 
states that he obtained from the purulent exudation in the pia mater, 
in a case of meningitis occurring with pneumonia, a microbe resem- 
bling that in the pneumonic exudation. 2 

The winter season is the most predisposing time of the year for 
the occurrence of cerebro-spinal fever. Statistics collected in Europe 
and the United States show that while one hundred and sixty-six epi- 
demics occurred in the six months commencing with December, there 
were only fifty in the remaining six months of the year. In New York 
City, where the state of the domiciles is about the same the year around, 
the season appears to exert little influence on the prevalence of the 
disease. 

Morbid Anatomy. — "In the apoplectiform cases ending fatally 
within twenty-four hours, there may be little or no visible alteration of 
the meninges ; but the brain is swollen, its convolutions are flattened, 
and the furrows obliterated. The characteristic appearances are to 
be seen toward the second half of the first week and later. They con- 
sist essentially in the manifestation of an acute leptomeningitis, serous, 
fibrino-serous, or purulent. The dura mater is tense, its free surface 
normal. The outer surface of the pia mater is also usually unaltered. 
The meshes, however, are infiltrated with more or less opaque yellow, 
serous, fibrinous, or purulent exudation, which often varies in char- 
acter in different parts of the brain in the same case. The inflam- 
matory exudation is generally most abundant at the base of the brain 
and over the convexities. In the former region it fills the space between 
the optic chiasm and the pons, and is abundant over the cerebral 
peduncles and on the upper surface of the cerebellum. Similar 
appearances are to be seen in the pia mater of the spinal cord, either 
throughout or over limited portions. The infiltration is usually more 
extreme on the posterior surface of the cord and in the most dependent 
portions, especially in the lumbar region. 

"The brain is pale, the convolutions are flattened, and the ven- 
tricles are distended with an opaque fluid from which yellow, viscid 
clots settle at the lowermost parts. The ependyma is swollen, soft, 
perhaps ecchymosed. If the patient dies during the later stages of the 
disease, the pia mater is thickened and opaque in patches and spots 



iEjen Klin. Gazeta, April 21, 1885. 

2 Deutsch. Med. Wochenscher, November 13, 1886. 



484 Cerebrospinal Meningitis. 

and adherent in places to the brain. The convolutions of the brain 
may be atrophied and the meshes of the pia mater oedematous. 

"There are splenic hyperplasia and grandular degeneration of the 
heart, liver, and kidneys. Bronchial catarrh is frequent, and atelec- 
tasis and hypostatic and lobular pneumonias are associated with the 
disease. The appearances characteristic of arthritis, endocarditis, 
pleurisy, nephritis, and enteritis are present when these affections com- 
plicate the course of the disease." (Wood.) 

Symptoms. — During the prevalence of cerebro-spinal fever, cases 
now and then occur in which the symptoms are mild and transient, and 
the health is soon restored. Occasionally, also, are reported cases met 
with during the progress of an epidemic which present more or fewer 
of the characteristic symptoms, but in so mild a form that the patients 
are never seriously sick, and never entirely lose their appetite; but the 
disease, instead of aborting, continues about the usual time. The 
course and symptoms of cerebro-spinal meningitis vary so greatly as 
almost to baffle concise description. 

The Mode of Commencement in an Ordinary Type. — It has been 
observed that cerebro-spinal fever rarely begins in the forenoon after 
a night of quiet and sound sleep. In seventy-two recorded cases by 
Louis, M. D., in the thirty-six severe and fatal cases the commencement 
was almost without an exception between midday and midnight. In 
young children convulsions in place of a chill may usher in the attack, 
or occur immediately after it; they may be partial or general, slight 
or severe. Stupor more or less profound, or less frequently delirium, 
succeeds. Mild cases more frequently than severe ones begin grad- 
ually, and with certain premonitions. The ordinary mode of com- 
mencement is, the patient is seized with vomiting, headache, and per- 
haps a chill or chilliness, which is especially common in adults, and 
the temperature rises to 101 or 102 degrees Fahrenheit. The pulse 
is slow, full, and strong; the face is livid, or perhaps pale, with an 
expression of great anxiety. As time passes, the headache increases 
in severity, and there is violent backache, a contraction of the muscles 
of the neck, and marked pain where the head is bent or flexed. The 
nervous disturbances grow more and more decided, until the muscles 
of the back are rigidly contracted, as in tetanus, or trismus, and neu- 
ralgia is not uncommon. In the graver cases semi-coma occurs within 
the first few hours, in which patients are with difficulty aroused, or 
profound coma, which, in spite of prompt and appropriate treatment, 
is speedily fatal. The pain frequently shifts from one part to another. 
The pupils are dilated, or less frequently contracted, and they respond 
feebly or not at all to the light if the attack is severe and dangerous ; 
they will often oscillate, and occasionally one is larger than the other. 
Delirium may follow immediately after the chill, and is almost 
invariably an early symptom. It may be wandering, but is often 
furious and maniacal. Sometimes there is an increasing stupor instead 
of delirium. 



Cerebro-Spinal Meningitis. 485 

The severe tinuitus aurium may be an easy symptom, showing that 
the special senses are affected; in the advanced stages of the disease 
deafness is almost universal. Double vision is an ordinary result of 
strabismus. A failure of the eyesight frequently marks the excessive 
pressure at the base of the brain. Skin eruptions are characteristic of 
the disease. Herpes labialis is very frequent and persistent, but the 
pathogenic eruption is that of petechias, which covers the whole sur- 
face of the body, beginning as small, bright, deep-rose, or purplish 
spots, or occurring in patches of various sizes, and in severe cases 
coalescing into great blotches over the body ; this eruption may develop 
as early as the third day, or it may be postponed as late as the eighth 
day. In some epidemics it is a marked feature, and in others it is 
almost altogether absent. In some epidemics we see it has been replaced 
or accompanied by urticaria, rubeoloid rashes. 

Louis, M. D., states that the highest temperature which he had 
observed was 107 f degrees Fahrenheit, in a child aged two years. This 
was in the commencement of the attack. Subsequently it fell a little, 
but rose again the third day to 107 degrees Fahrenheit, when she died. 
In two other cases the temperature was 106 degrees Fahrenheit on the 
first day, and it did not afterward reach so high an elevation. One of 
these cases resulted in death on the ninth day, and the other in the 
ninth week. Wunderlich has recorded a temperature of 110 degrees 
Fahrenheit in two cases, with, of course, an unfavorable ending. 

The following is a common example of the sudden thermometric 
changes observed in children of two years of age: "The temperature 
varied from 101 to 104 | degrees Fahrenheit as the extreme, while that 
of the fingers and hands at the first examination was 90? degrees 
Fahrenheit, at the second examination 90 degrees Fahrenheit, at the 
third 103 degrees, and at the fourth 83 degrees. Hence, at the third 
examination the temperature of the extremities had risen 13 degrees 
Fahrenheit, so as nearly to equal that of the blood, and at the fourth 
examination it had fallen 20 degrees Fahrenheit, The patient recov- 
ered." 

The great and sudden variations in the pulse and the internal and 
external temperature have considerable diagnostic value in obscure and 
doubtful cases. 

The average temperature of cerebro-spinal meningitis is distinctly 
lower than that of most of the serious continued fevers. It is usuallv 
below 100 degrees Fahrenheit; rarely does it reach above 103 degrees 
Fahrenheit, but fatal cases run high. 

The difference between the morning and the evening temperature 
may be very great, but it may be wanting. Sometimes the maximum 
temperature occurs in the morning; the only characteristic features of 
the temperature curve are its great irregularity and the failure to 
follow any definite course. 

There are two chief varieties of malignant epidemic meningitis: 
In the apoplectic or cerebral type the symptoms are violent headache,' 



486 Cerebrospinal Meningitis. 

rapidly-developed delirium with or without retraction of the head, 
great vital depression, moderate elevation of temperature, and a feeble 
pulse, which may be slow or rapid. Death in coma may occur in six 
or eight hours. In the second type there is vital depression, with 
clearness of intellect, moderate or high temperature, and the almost 
immediate appearance of ecchymoses on various parts of the body, 
which spread rapidly and involve the whole surface in dark purple 
spots; death occurs within twenty-four hours. 

Anomalous forms of cerebro-spinal meningitis are recorded and 
described by Fitz. One is that which is sometimes known as the inter- 
mittent type, in which the fever is remittent or intermittent, with 
paroxysms which occur daily or every second day. A second variety 
is that which may be termed the neuralgic or rheumatoid, in which the 
pains in the legs and arms are extremely violent, accompanied by great 
hyperesthesia, and it may be excessive pains on movement, and even 
by pronounced redness and swelling of the joints. There are two 
abortive forms, one in which the symptoms are throughout mild, and 
one in which the onset may be furious, with very threatening symp- 
toms and high temperature, which, however, subside after a' few hours, 
or at the most in three or four days, and leave no abiding ill effects. 

Another form of the disease which is especially commented on 
by Hubner is the chronic, in which the course is protracted over many 
months, with remission and intermission, and recurrence of fever, 
and with very varying symptoms. In most of such cases there are 
pronounced evidences of basal meningitis, with great loss of strength 
and wasting. 

The following are the abnormal appearances of the skin: First is 
most frequently observed the papilliform elevations, the so-called 
goose-skin, due to contraction of the muscular fibers of the corium. 
This is often seen in the first week. Second, a dusky mottling, also 
common in the first and second week in grave cases, is most marked 
when the temperature is reduced. Third, numerous minute red points 
over a large part of the surface, bluish spots a few lines in diameter, 
due to extravasation of blood under the cuticle, resembling bruises in 
appearance, and large patches of the same color, an inch or more in 
diameter, less common than the others, of irregular shape as well as 
size, and usually not more than two or three upon a patient. These 
last resemble bruises, and they may sometimes be such, received during 
• the time of restlessness ; but ordinarily it is said that extravasations of 
this kind result entirely from the altered state of the blood. 

This cutaneous disease evidently has a nervous origin, the vesicles 
occurring in most instances on those parts of the surface which are 
supplied by branches of the fifth pair of nerves ; its most common seat 
is upon the lips, occasionally upon the cheek, upon and around the 
ears, and upon the scalp. During the first days the skin is frequently 
dry; afterward perspirations are not unusual, and free perspirations 
sometimes occur, especially about the head, face, and neck. 



Cerebro-Spinwl Meningitis. 487 

The course of epidemic meningitis is entirely (as it has been 
observed by writers) irregular from day to day, and also as to its dura- 
tion. In fatal cases death usually occurs almost immediately, or it 
may be postponed beyond a month. Even in favorable cases, con- 
valescence may be prolonged almost indefinitely, due, as it is said, 
largely to local changes, and it is usually accompanied by gradual sub- 
siding of the symptoms of meningitis, not rarely interrupted by 
relapses. Permanent loss of hearing is very common, producing in 
young children deaf-mutism. 

Sequels which follow the disease are, partial or complete amauro- 
sis (not rare), weakness or loss of memory, general impairment of 
intelligence, and even chronic hydrocephalus, local paralysis of various 
kinds, disorders of speech, and epileptic attacks. Bronchitis, atelec- 
tasis, hypostatic congestion of the lungs, and broncho-pneumonia are 
common occurrences in the course of the disease. 

Diagnosis. — The diagnosis of cerebro-spinal meningitis is, during 
an epidemic, ordinarily not difficult. On account of the nature and 
variety of its symptoms, and the suddenness of its onset, it may be mis- 
taken for scarlet fever, and vice versa. Redness of the fauces will 
settle that question within a few hours ; later will be seen the character- 
istic efflorescence which appears on the skin in scarlet fever. 

In sporadic cases it is necessary to determine the non-existence of 
tubercle, otitis media, syphilic, or any other cause for an existing 
meningitis which has been observed. Continued fever, typhus, or 
typhoid fever, may so resemble cerebro-spinal meningitis that it requires 
great care on the part of the practitioner to avoid mistake. The pres- 
ence of herpes or of any non-syphilitic skin eruption is usually in favor 
of the epidemic disease. Rheumatism or pneumonia with meningeal 
symptoms is often seen. The shifting irregularity of the symptoms, 
the peculiarities of the range of temperature, the non-conformity of 
the febrile and other manifestations of the type of the pneumonia, or 
the typhoid, or whatever other disease it may simulate, should excite 
suspicion, while characteristic rigidity and muscular contraction and 
distinct stiffness of the neck, under such circumstances, should be 
looked on as conclusive. A septic meningitis is made out by finding 
the point of infection. Some of the milder cases of cerebro-spinal 
fever might be mistaken for hysteria, but the pain in the head and 
elsewhere, the muscular rigidity, and especially the occurrence of more 
or less fever, enable us to make a diagnosis. 

Prognosis. — Cerebro-spinal meningitis is regarded as one of the 
most dangerous diseases of childhood. It is dreaded, not only on 
account of the great mortality which attends it, but also on account of 
its protracted course, the suffering it causes, the possible permanent 
injury to the important organ which it chiefly involves, and often the 
irreparable damage which the eyes and ears sustain. 

Under the age of Hve years, and over that of thirty, the prog- 
nosis is said to be less favorable than between these ages. ' An abrupt 



488 Cerebro-Spinal Meningitis. 

and violent commencement, profound stupor, convulsions, active 
delirium, and great elevation of temperature, are symptoms which 
should excite solicitude and render diagnosis guarded. If the tem- 
perature remains above 105 degrees Fahrenheit, death is probable, even 
with moderate stupor. 

Treatment. — Cerebrospinal meningitis should be treated in 
accordance with the general principles that govern the management of 
infectious fevers. Where epidemics exist, where anti-hygienic condi- 
tions prevail, we must look to the removal of such conditions, procure 
pure air in the domicile, wholesome diet, and a quiet and regular mode 
of life; all measures designed to produce the highest degree of health 
Ave of the first importance for the prevention of the disease. Cleanli- 
ness of the streets and areas (no decayed vegetable matter should exist 
about the premises), as well as of the apartments, good sewerage and 
drainage, the prompt removal of all offending or refuse matter, avoid- 
ance of overcrowding, — in a word there should be the strictest observ- 
ance of sanitary requirements in every particular. 

To enjoin quiet and a regular mode of life as a preventive measure 
during the occurrence of an epidemic of cerebrospinal meningitis or 
fever, is consistent with the theory that the disease is caused by a micro- 
organism. 

The nursing should be most careful, and the saving of the patient's 
strength is most necessary. The diet should be simple, nutritious, and 
adapted to the digestive powers of the individual patient ; milk, animal 
broths, eggs, oysters, and farinaceous foods are necessary. 

Local venesection, by the abstraction of blood with leeches, or with 
cups to the temples or to the back of the neck, is recommended by Stille 
and others. In many cases this greatly mitigates the pain and relieves 
the local disease. It is recommended that local blood-letting be prac- 
tised with caution. Blisters have been largely used and strongly recom- 
mended. It is plain that the most that can be accomplished by them is 
relief of the meningeal and cerebral congestion, and that there is dan- 
ger, if they are used too severely, of producing violent local inflamma- 
tion, which may, as the dyscrasia of the disease becomes more and more 
developed, take on a very serious form. Therefore, vesication should 
be superficial always, and in order to be effective, must cover a large 
surface. It should be entirely avoided when the symptoms of the 
breaking down of the blood are pronounced. The best site of the blis- 
ter is from the nape of the neck upward over the occiput (the head 
being shaved). The continuous application of cold by means of ice- 
bags to the head and upper part of the spine is of great importance, and 
it is thought that it probably has as much effect upon the local disease 
as has local blood-letting on counter-irritation. 

A liniment of chloroform and oil of peppermint, used sparingly, 
rubbed up and down the spine, seems to give temporary relief, and does 
not hinder the use of the ice-bag. Dr. William H. Sutton, of Dallas, 
Texas, recorded a case of a child three and a half years of age, who 



Cerebro-Spinal Meningitis. 489 

had been under treatment for supposed continued fever. When Dr. 
Sutton assumed control of the case, November 20, 1877, "the pupils 
were dilated and insensible to light ; features pallid and pinched ; pulse 
130; temperature 103 degrees Fahrenheit; the patient totally uncon- 
scious. November 21, morning temperature 105 degrees Fahrenheit; 
pulse 140; evening temperature 101i degrees Fahrenheit; pulse 120. 
November 22, morning temperature 106-J degrees; pulse 160; restless; 
evening temperature, 105% degrees; pulse 120. The patient had not 
slept, except for a few moments, for nearly two weeks. A strip of 
flannel saturated with turpentine was placed over the spine from the 
neck to the sacrum, and a hot smoothing-iron was run iip and down it, 
and eight drops of the fluid extract of ergot were given every three 
hours. The father of the child stated to Dr. Sutton that as soon as the 
application was finished, the child fell asleep, and slept several hours, — 
the first for two weeks, — and the fever rapidly declined. From this 
time on he began to improve, and gradually and fully recovered." 

The use of stimulating applications to the spine in cerebro-spinal 
meningitis has been long known, but the mode of application is novel. 
However, in cases of wry neck, "crick in the neck/' or stiff neck, the 
above is an old-time method of using stimulating applications among 
the colored race in the southern states. 

Internal Treatment. — The same remedies are recommended by 
some and condemned by others. The physician will treat his patient 
according to the general conditions of the case, treating symptoms as 
they arise. When there is high temperature, cold should be applied, 
opium to relieve pain in some cases ; in other cases chloral hydrate is 
useful, especially in cases of eclampsia, or of symptoms threatening 
eclampsia. Bromide of potassium acts promptly on some young chil- 
dren, producing quiet. It causes contraction of the minute blood- 
vessels of the nerve-centers so as to diminish hyperesthesia, as was 
shown by Dr. Putnam-Jacobi in his experiments, and by others also; 
and at the same time it is claimed to diminish, in a marked degree, the 
reflex irritability of the spinal cOrd. Many children, it is said, are 
saved by its timely use from the dangers of eclampsia; and by its 
sedative effect on the nervous system and contractile action on the capil- 
laries, it probably diminishes the intensity of the inflammation and the 
amount of exudation. Dr. Squibb recommended it dissolved in simple 
cold water, which may or may not be sweetened ; give four grains every 
two hours to a child two years old who has the usual restlessness and 
apparent headache, and six grains to a child five years of age. Ergot 
is recommended as another very important remedy. It is scarcely less 
useful than the bromide, as it aids in contracting the arterioles and 
diminishing the flow of arterial blood. In New York City, Squibb's 
fluid extract has been more usefully prescribed than other prepara- 
tions. The efficacy of ergot is more marked during the first and second 
weeks, when the congestion of the nerve-centers is greatest. At a more 
advanced stage, when congestion occurs, and the danger arises from 



490 Cerebro-S pined Meningitis. 

inflammatory products and structural changes, the time for the use 
of ergot is passed, or if it is still of service, it is less needed than at 
first, and should be given less frequently. Chloral in proper doses 
rarely fails to give quiet sleep, and it is supposed by some who have 
studied its therapeutic action that it diminishes the cerebral circulation. 
It is, therefore, beneficially prescribed with bromide ; five grains for a 
child six to eight years of age, administered with the bromide. 

Antipyrine is used by some practitioners for the purpose of reliev- 
ing the headache; it may be administered with the bromide. Quinine 
apparently does no good; it is only used as an anti-periodic. 

When the acute stage has passed, measures should be taken to 
remove the serum which sometimes remains. For this iodide of potas- 
sium is thought to be more useful than any other agent ; it is adminis- 
tered early along with the bromide. 

The result depends to a great extent on the nursing. The skill 
of the physician may be thwarted, and the life of the patient lost, by 
inefficient nursing. No other disease more urgently requires kind, 
intelligent, and constant attendance night and day on the part of the 
nurse. Nutriment as well as the medicine must be punctually given. 
Constant readjusting of the ice-bags is required, and during the long 
period of convalescence the utmost care is needed to remove the excre- 
tions at once, in order to prevent bed-sores. Alcohols must be 
employed in proportion to the existing exhaustion; laxatives to over- 
come constipation, and mild diuretics if the renal secretions fail. 

The room should be dark, well ventilated, and quiet. All sym- 
pathizing friends who are not required in the nursing should be 
excluded. I know of no other disease in which this injunction is more 
necessary, for mental excitement may produce a dangerous aggrava- 
tion of symptoms. 



CHAPTER XXXII. 
SCARLET FEVER. 

Definition. — This is a contagious febrile disease due to a specific 
contagion, and characterized by a peculiar diffused eruption and a pro- 
nounced tendency to the development of serious sore throat. 

Etiology. — Scarlet fever is due to a specific poison capable of 
reproducing itself, which may pass directly by contact with the person 
of the sick, or be transmitted through the air, or be carried by fomites. 
The power of the poison to resist change is very great, as is 
also its ability to pass into milk and other articles of food, and to 
adhere to letters, furniture, toys, flowers, locks of hair, and other 
media of transmission. Experimental and chemical observation points 
to the existence of a scarlatinal microbe, but such organism has not 
been isolated or demonstrated. It is important to know that diph- 
therial organisms can often be obtained in abundance from the pseudo- 
mebranous angina of scarlet fever ; but, on the other hand, the most 
violent sore throat with abundant exudate may exist without the 
diphtheritic bacillus. 

The varying predisposition, susceptibility, and immunity of indi- 
viduals and families are as remarkable as they are inexplicable. In a 
family of children one or more may escape or suffer but a mild attack, 
while the remaining members may, without apparent cause, exhibit the 
most intense susceptibility. Families residing in close proximity, per- 
haps in adjoining houses, and subject alike to the infection, may be 
very differently influenced. In one the most aggravating form of the 
disease may prevail, and the other will be protected by a special 
immunity. This absence of susceptibility may continue throughout 
life, or only during the prevailing epidemic, or it may continue during 
residence in one locality and disappear upon removal to another in the 
same city or to some distant village or city. Predisposition may be 
increased or diminished by locality. Rapid and fatal cases indicate 
extraordinary susceptibility. Social position and external circum- 
stances influence the mortality, but do not seem to affect the predispo- 
sition. The death-rate increases with poverty and diminishes with 
affluence. Age exerts a very decided influence. !N*o age is exempt. 
Children have been bom with scarlet fever, and newly-born infants 
are occasionally attacked, but during the first year the susceptibility is 
not very marked. It is increased during the second year, but between 
two and seven years it is most intense. After the tenth year statistics 
show that the liability is greatly diminished, and more so after the 

(491) 



492 Scarlet Fever. 

fifteenth year. If children can be protected during the first ten years 
of life, the chances of escape are greatly enhanced, and the danger is 
greatly lessened. 

Prevention. — There is no effectual method of protecting the sus- 
ceptible from the contagion of scarlet fever, except by isolation of the 
sick and by non-intercourse. 

All experiments to secure protection by the internal administra- 
tion of drugs have failed. It is said to be undoubtedly true that fre- 
quent bathing and inunctions during the period of desquamation will 
effectually prevent diffusion of the cast-off particles of the epidermis 
in the surrounding atmosphere, and thereby limit to a very considerable 
extent the dissemination of the poison; but it is not believed that the 
vitality of the poison is lessened. Walforcl claims that the use of 
arsenic given during the incubation stage will prevent or greatly 
modify the disease. He employs the liquor arsenicalis in as large dose 
as the age of the child will permit, in combination with sulphurous acid 
and syrup of poppy. The dose should be given daily for several days, 
then less frequently. 

Separation and disinfection are the most effecual prophylaxes. 
Disinfect in a similar manner as in typhoid fever. (See Typhoid.) 

Incubation. — The period of incubation varies, being in the vast 
majority of cases from two to eight days. There are, however, many 
exceptions to the general law. In occasional instances (of recorded 
cases) the disease has developed in a few hours after the first and only 
exposure ; in other instances it has been delayed for several weeks. At 
least three weeks should elapse before the child is pronounced past the 
time for the contagion to make its appearance. 

Pathological Anatomy. — The morbid anatomy in scarlet fever con- 
sists mainly in the changes which take place in the integument sub- 
cutaneous, connective tissue and mucous membrane of the oral and 
nasal cavities and throat and kidneys. The skin is hypersemic, and the 
surface is more or less covered with the exanthema, which consists of 
numerous and closely-aggregated points, slightly red in the beginning, 
but rapidly increasing in redness, sometimes to a brilliant scarlet color. 
The points may be flat or slightly elevated, are usually circular in form, 
but may be elongated; marked confluence with vivid redness denotes 
increased hyperemia. 

The exanthema usually maintains its maximum development for 
one or two days, rarely less than one day, and then gradually fades, to 
disappear with the beginning of desquamation. 

There may be an adherent false membrane due to the presence of 
bacteria, sometimes of the diphtheria bacillus. Superficial ulceration 
and deep necrosis of the tissues are not infrequent. In some instances 
the neighboring lymphatic glands are swollen and injected, and may 
contain abscesses, while the surrounding fibrous tissue is oedematous. 
Granular degeneration of the heart and liver and moderate acute 
enlargement of the spleen are present. 



Scarlet Fever. 493 

Symptoms. — The ordinary period of incubation of scarlet fever is 
from three to five days, though well-authenticated cases have been pub- 
lished by Trousswaus and others in which it has developed in twenty- 
four hours, while it may be prolonged to ten or even twelve days, or as 
long as three weeks. 

The regular form is characterized by a well-marked exanthema 
angina, and more or less fever. It may begin suddenly, or be pre- 
ceded by a day or two of indefinite indisposition, during which time 
the patient will complain of headache, with general malaise, and loss of 
appetite. The tongue will be slightly coated. The bowels, as a rule, 
are constipated; occasionally there may be some looseness. In some 
cases there will be marked sluggishness, and in others fretfulness with 
loss of sleep. Most frequently the disease begins most suddenly with a 
chill, vomiting, a convulsion, or a high fever, associated with the usual 
phenomena of high febrile action, — headache, frequent pulse, flushed 
face, thirst, sparkling eyes, anorexia, twitching and starting, and per- 
haps delirium or stupor. A slight diarrhea may supervene. These 
symptoms continue without abatement, and sometimes are increased, 
until the appearance of the eruption, which may occur in a few hours, 
or be delayed one, two, three, or five days, or later. 

The rash appears first about the neck, chest, and shoulders, in 
indistinct points, increases rapidly in redness, and extends over the 
trunk and extremities, reaching its maximum development in rare cases 
during the first day, but most usually during the second, and in some 
cases not before the third or fourth day. Under pressure with the 
fingers the color disappears, but reappears immediately upon removal of 
the pressure. Ordinarily the rash is uniform, but it may be in patches. 
It is especially dark colored in the groin, and in the folds of the skin 
made by flexion of the skin. On the nose, lips, and chin the rash may 
be wanting, while it is always very pronounced on the cheek. The 
eruption attacks the mucous membranes, so that the cheek and the throat 
are a brilliant red, swollen, and often distinctly punctated. The tongue 
is covered with whitish fur, with red papillae, called "strawberry 
tongue." A few days later desquamation leaves the surface of the 
tongue red and rough, with greatly enlarged, very dark red papillae, — 
"raspberry tongue," — a condition which may last live days. x\t this 
stage the tonsils are swollen, and their crypts distended with a yellowish- 
white creamy exudate, which often spreads over the surface, making a 
sort of false membrane. 

Lasegue's contention that at this stage there is a vascular eruption 
upon the mucous membrane, seems plausible. The submaxillary glands 
and the surrounding cellular tissues are always swollen. The lips are 
dry and crack at the angles. Niven says the breath is peculiarly sweet, 
almost aromatic, in the early stage of the disease ; but when the angina 
is severe, and more especially when ulceration occurs, the breath is 
foul and fetid if suppuration and sloughing have taken place. 



494 Scarlet Fever. 

Sudden and marked elevation of the temperature, with correspond- 
ing rapidity of the pulse, is one of the most common initial and char- 
acteristic phenomena of scarlet fever. At the onset the fever may 
reach 102 degrees Fahrenheit, and rapidly rise during the day to 105 
degrees or 106 degrees Fahrenheit. In some cases it may reach even 
a higher elevation of temperature in a few hours. In a majority of 
cases it will either continue during the period of development and 
maximum intensity of the exanthema to range between 102 degrees 
and 104 degrees Fahrenheit, or gradually rise during each succeeding 
day until the exanthema has reached its maturity, and then lessen daily 
with the disappearance of the rash, until the normal is reached with 
the beginning of desquamation. The course of the fever is marked 
by remissions and exacerbations. In this form the temperature does 
not often reach over 106 degrees Fahrenheit, and the highest point 
is usually reached during the period of maximum intensity of the rash. 
With the rise and fall of the temperature the color of the rash varies, 
increasing with the elevations and lessening with the remissions. Dur- 
ing the period of high fever there is usually active delirium, in some 
cases stupor, and in others twitching and jerking, tossing about in 
the bed, moaning, and occasionally screaming as if in pain. 

The pulse ranges high from the beginning, and continues so with 
corresponding increase in frequency with the rise of the temperature, 
sometimes reaching 160 or more per minute. It diminishes in rapidity, 
but not correspondingly with the fall of the temperature. Usually 
it continues rapid until convalescence is established. Sometimes the 
temperature drops and the rash fades on the second or third day, both 
to reappear in a day or two. While the protective powers of an attack 
of scarlet fever can not be denied, yet it is certain that, in susceptible 
individuals, there may be repeated attacks, which consist simply of 
a bad- sore throat with some febrile reaction. 

Three types may be recognized : The simple, the anginose, and the 
malignant. 

The simple scarlet fever is that characterized by a contagious 
febrile disease, and a peculiar eruption diffused, and a pronounced 
tendency to the development of serious sore throat. 

In the anginose scarlet fever the throat symptoms appear very 
early, and are attended with great swelling, and with the rapid forma- 
tion of a membranous exudation, which may extend upward into the 
nostrils, and forward into the mouth, and downward into the pharynx 
and larynx. 

Irregularities of the angina are frequent. Instead of declining 
with the disappearance of the rash, it may become worse. Suppura- 
tion and gangrene may occur. Diphtheria may set in at any time, 
either during the continuance of the angina or after it has subsided. 
The implication of lymphatic and glandular structures in close prox- 
imity may persist and progress to the formation of abscess. The regu- 
lar may be transformed into the irregular form at any stage by the 



Scarlet Fever. 495 

development or aggravation of a pre-existing local affection. It quite 
often happens that a case will pursue a regular course for a time, and 
then suddenly assume an irregular and graver form. In rare instances 
this is liable to occur independently of any local affection, and is prob- 
ably due to some constitutional peculiarity. 

The excessive fetor, the rapid swelling of the glands of the neck, 
and the tendency to necrosis of the mucous membrane, may make a 
picture indistinguishable from that of malignant diphtheria, and death 
may result from septicaemia produced by the local disease of the throat, 
or ulcers may open the carotids, or blood-vessels, and cause fatal hem- 
orrhage. 

Inflammation of the Eustachian tube and of the middle ear are 
common phenomena. 

Malignant Forms. — This form of scarlet fever, fortunately, is 
not so common as the others. It refers especially to the combinations 
of dangerous nervous symptoms with hyperpyrexia. Its beginning is 
expulsive, so to speak. The initial symptoms are violent headache, 
vomiting, dyspnoea, high fever, cyanosis, convulsions, delirium and coma, 
which sometimes continue without abatement for one, two, or four 
days, when death takes place ; or the attack may seem not overwhelming, 
but be followed in a few hours by violent adynamia, with great heart 
failure, weakness of the extremities, excessive dyspnoea, and nervous 
phenomena. Sometimes the malignant symptoms first develop after 
the appearance of the eruption, which may be intense and widespread. 
Then, again, a case may appear with convulsions, followed by coma 
and death within twenty-four hours, before the appearance, or time 
for the appearance, of the rash. In most cases of malignant scarlet 
fever, vomiting is most pronounced, and often there is diarrhea. A 
sudden rise of temperature immediately preceding death is also fre- 
quent, even at a time when the extremities are very cold, and the 
patient in collapse. In the hemorrhagic malignant scarlet fever, epis- 
taxis and abundant hematuria may precede or follow the occurrence of 
the purpuric and petechial eruption, and death may take place almost 
immediately in collapse, or be preceded by intense fever, violent dys- 
pnoea, convulsions, and delirium. A rare form of malignant scarlet 
fever is that wherein all the symptoms are lost in a furious choleraic 
diarrhea. 

Eelapses in scarlet fever are rare, but do occur, with the reappear- 
ance of the fever, the sore throat, and the eruption. The time of their 
appearance is from twelve to thirty-six days after the first attack. 

C (implications and Sequelae.— These are too numerous to men- 
tion all; to some only brief references will be made. The complica- 
tions of scarlet fever are often very serious. Diphtheria may develop, 
and is usually a fatal complication. There may be a widespread gan- 
grene of the throat without diphtheria. Aggravated angina, attended 
with ulceration and sloughing, is a serious and sometimes fatal compli- 
cation. In some cases the enlarged lymphatic glands harden into a 



496 Scarlet Fever. 

brawny mass, exceedingly intractable to all medical treatment. Middle- 
ear inflammation is said to occur in about thirty per cent of the cases, 
and according to Burkhart-Merian a severe suppurative otitis-media 
develops in about four and a half per cent, usually during the period 
of eruption, revealing itself by violent earache, insomnia, and excessive 
tenderness of the mastoid processes. Few cases escape a mild coryza. 
Bronchitis and pneumonia are not so frequent complications as inflam- 
mations of the serous membranes. Pleurisy, peritonitis, pericarditis, 
and endocarditis are rare but grave complications. They usually set 
in during the second week of the disease. 

Pleurisy and pericarditis are said to be generally associated with 
joint inflammations, which ordinarily follow the course of so-called 
scarlatinal rheumatism. Of this disease there are three forms: That 
in which the exudate is serous ; that in which it is primarily serous and 
secondarily purulent ; and that in which pus is formed from the begin- 
ning. The affection generally begins from the fifth to the seventh day 
of the fever, or rarely during the stage of desquamation. It sometimes 
attacks many joints, but is usually localized in a single articulation. 
Recovery in the course of a few days is common with the serous exudate ; 
recovery with more or less permanent changes in the joint is the rule 
when the exudate is first serous and then purulent; but when from 
the beginning pus forms in the joints, death from pyaemia is the 
common ending. It is thought that these complications are due to 
streptococcus poison from the throat. Convulsions occur often at the 
onset of the disease, and are not necessarily an alarming symptom ; but 
when recurring or occurring during the progress of the disease, they 
are a very fatal complication. Nervous disturbances of variable char- 
acter are usually not severe; hemiplegia, chorea, paraplegia, mania, 
and paralysis of single nerves have been observed. Neuralgia, hyper- 
aesthetic and anaesthetic conditions, epilepsy, hysteria, and a variety of 
mental disturbances, have followed scarlet fever. 

Nephritis. — Nephritis may appear as either a complication or a 
sequel of scarlet fever, and is considered the most important. As a 
sequel it may not appear for several weeks after convalescence. No 
patient ought to be considered safe until six weeks have elapsed. In 
some cases it is febrile phenomena, but in most cases it is the effect of 
scarlatinal poison, and in others it may be due to indiscretion in diet 
or to improper exposure. The characteristic nephritis of the disease 
develops most frequently in the second or third week to the fourth or 
sixth week. It may appear in a mild form of the disease, and come 
on when all the symptoms seem most favorable. The first evidence is 
the diminution in the quantity of the urine, and usually an anasarca 
just below the eyes, which often is first detected in the early morning. 
The nephritis varies greatly in intensity; in the severest forms there 
are aching pains in the back, chills, vomiting, hematuria, and partial 
or even finally complete suppression of the urine, with ursemic symp- 
toms after some hours. In other cases the symptoms are so mild that 



Scarlet Fever. 497 

they are scarcely to be noted, consisting of a little albuminuria, a few 
casts, and some oedema. Dropsy is usually later, but may be one of 
the early symptoms. Oedema of the lungs and acute oedema of the 
glottis are more frequent in severe than in mild cases of scarlatinal 
nephritis, but may suddenly appear in any case. 

Diagnosis. — In a majority of cases, when first seen by the physi- 
cian the diagnosis is made at a glance. The diagnosis of scarlet fever 
in the stage of incubation depends upon the severity of the symptoms ; 
the presence of vomiting, and the rapid rise of temperature, a char- 
acteristic exanthema, and angina, or either separately, with a moderate 
or a high fever, will be sufficient. The prevalence of the disease, or 
the fact of the exposure of a susceptible person to the contagion, is 
always proof, and frequently in cases of doubt is sufficient to establish 
the diagnosis. The rashes produced by antipyrine, belladonna, oil of 
copaiba, and some other drugs, resembling somewhat the rash of scarlet 
fever, may be excluded by the absence of sore throat and fever with 
the presence of other symptoms of poisoning, which usually make the 
diagnosis not difficult. 

The diagnosis between diphtheria and scarlet fever is not always 
possible, because diphtheria is sometimes accompanied by a scarlatinal 
rash, whilst Loeffler's bacillus may be present in scarlet fever. The 
pure diphtheria may simulate scarlet fever, and frequently both dis- 
eases are associated together; and, fortunately, so far as treatment is 
concerned, it would be precisely that of diphtheria simulating scarlet 
fever. 

Prognosis. — The mortality in scarlet fever varies in different epi- 
demics and under different circumstances from one to forty per cent, 
according to the various authors upon the subject. In children under 
one year the death-rate is very high, but it diminishes after the first 
year, until it reaches its minimum between six and twelve years of age. 
Any previous disease greatly increases danger. Pyaemia and septi- 
caemia are usually fatal. Continuous delirium and coma are ordinarily 
the signs of a speedy death. Abundant hemorrhagic extravasations, 
hematuria, however mild, — these signs are accepted as unfavorable, and 
very painful swelling of the submaxillary gland is of evil import. The 
majority of cases of nephritis recover under careful treatment, but a 
complete early suppression of urine is very dangerous. 

Treatment. — Absolute isolation in a freely-ventilated room, with all 
the precautions as to antisepsis and asepsis in general, and good hygiene, 
etc., which have been thoroughly discussed in typhoid fever (see 
Typhoid), are essential in the treatment of scarlet fever. The attend- 
ing physician should carefully supervise the disinfection of the sick- 
room. It is said there is no remedy which has the power to affect the 
course of the fever ; the symptoms must be met as they arise. Wood 
recommends: a When the vomiting is very severe, carbonic-acid water, 
lime-water and milk, and bismuth will often be found effectual. If 
these fail, a quarter of a grain of cocaine, in solution, every one or two 

32 



498 8cmiet Fever. 

hours, may be tried for a few doses, for the relief of nervousness and 
insomnia ; the bromides, trional or sulphonal, and chloral, used care- 
fully, are of value. Hyascine in very minute doses is said to act well 
in controlling the delirium and producing sleep ; but it is an extremely 
dangerous remedy, as by increasing the dryness of the throat and prob- 
ably also producing paralytic weakness of the throat, it tends greatly to 
increase symptoms of suffocation in anginose cases; we have seen it 
apparently cause death in this way. In order to maintain the secre- 
tions, and especially to lessen the strain upon the kidneys, the child 
should be encouraged to drink cold water, simple or carbonated, freely. " 
Shakhovsky asserts that salicylic acid will prevent all complications, 
such as uraemia, dropsy, diphtheria, anginas, and lymphadenitis, and 
will remove them when present. He employs the following formula : — 

Ijc: Acid salicylic gr. xv 

Aqual distill, fervid gij 

Syrup aurantii 3J 

Mix. 

Give from one to four teaspoonfuls every hour during the day- 
time and every two hours by night; to prevent relapses the mixture 
must be continued at longer intervals for several days after deferves- 
cence. 

There are other authors who claim that salicylic acid, mercurials, 
and belladonna have no power to affect the course of the fever, although 
they have been recommended as specifics. 

Antipyretic treatment is most essential. Phenacetine, antipyrine, 
and antifebrine will reduce the temperature; but grave danger often 
accompanies the free use of any of these remedies, although, on the 
other hand, small doses, given at regular intervals, may do great good 
in quieting the nervous disturbances and aid in reducing the tempera- 
ture. Quinine has been strongly recommended ; but it has to be given 
in large doses to have any distinct effect, a practise which, in the 
opinion of some authors, is not thought to be justifiable. On the other 
hand, if given in moderate doses, it is probably of service, being 
intended to reduce the temperature as well as to support the nerve 
centers. The bisulphate is recommended as the best form, as it is more 
easy of absorption ; and if the stomach becomes irritated by its use, 
it should be given by the rectum, not in suppositories, but in slightly- 
acidulated (tartaric-acid) solution. 

When the temperature of scarlet fever, which is 102.5 degrees 
Fahrenheit, does not last over a few days, it does very little harm. 
When it rises to 103 degrees Fahrenheit or above, cold should be 
used externally, first, by sponging, and if this fails, by packing 
or by bathing. The temperature of the bath must be in propor- 
tion to the resistance of the fever; in most cases a bath temperature 
of 85 degrees Fahrenheit, gradually reduced to 80 degrees or 75 degrees 
Fahrenheit, is said to be the best. The cold pack, or the bath, or 



Scarlet Fever. 499 

whatever means are employed, must be used until the desired effect 
is produced, and the treatment is to be repeated whenever the tempera- 
ture rises to 103 degrees Fahrenheit. Leeter's tubes are recommended 
to be applied to the head and to the abdomen, and, with ice-water 
run through them, these sometimes suffice. The more rapidly the 
water passes through the tube, the more rapid is the abstraction of 
heat. This method has accomplished satisfactory results in cases where 
antipyrine has proven dangerous because of the collapse following its 
use. Alcoholic stimulants may have to be resorted to while the abstrac- 
tion of heat is being accomplished, so as to avoid exhaustion. If heart 
failure is threatened, alcohol, digitalis, quinine, and the carbonate of 
ammonia may be demanded. In taking a patient out of the bath there 
may be a tendency to relapse, when stimulants must be freely used 
just before the patient is put to bed. It may sometimes be very neces- 
sary to apply hot-water bottles or bags to the extremities while the 
patient is in the bath. 

The constitutional treatment (adynamia) in scarlet fever is sim- 
ilar to that of exhaustion from other fevers. (See Typhoid Fever.) 
On account of the irritation of the stomach or its tendency to irri- 
tation, and also of the kidneys, ammonium carbonate and any irritat- 
ing drugs must be avoided. 

The local external use of ice by India-rubber bags fastened about 
the neck, or around the neck underneath the jaws, is often advantageous, 
while small pieces of ice may be allowed constantly to melt in the 
mouth. Potassium has been largely used in scarlet fever, and is often 
of service as a local remedy to the throat. Spraying the throat out 
with peroxide of hydrogen solution has seemed to us the best of all 
local treatment. The official preparation may be used in full strength 
or diluted one-half. The nostrils should also be sprayed if there is a 
Tendency to the nostrils closing; if possible they should be sprayed 
from behind if not from the front. ' Tincture of ferric chloride, solu- 
tion of silver nitrate, glycerite of tannin, and various other astringent 
solutions are employed by different physicians as local applications. 
When suppuration of glands occurs, a free incision should be made 
at once. Cosmoline will allay the itching and burning of the skin; 
also cocoa butter, cold cream, olive-oil, or other bland fats, as goose 
or turkey oil, should be freely applied to the surface of the body morn- 
ing and evening after the first or second day of the eruption. 

When the eruption retrocedes or fails to develop, a hot mustard 
bath, or, if there be high temperature, the cold mustard bath, will 
often suffice. The treatment of nephritis is the same as that of acute 
nephritis from other causes. 



CHAPTER XXXIII. 

DIPHTHERIA. 

^ Diphtheria is one of the most dreaded, one of the most fatal, and 
one of the most common maladies of childhood. It is a highly con- 
tagious disease, characterized by fever, usually by a pseudo-membranous 
inflammation of the pharynx, and often by symptoms of a toxaemia 
due to the presence of a specific bacillus, whose growth produces the 
poison which is absorbed. The specific principle is ordinarily 
received by the inspiration of infected air, but it is sometimes received 
by direct contact of infected matter with one of the surfaces not lying 
in the respiratory tract. 

Etiology. — Oertel's views in regard to the virus of diphtheria 
express all that is known at present of the etiology of the disease. The 
nature of the virus is still obscure ; it acts upon cells, causing their 
death and disintegration, and the infected particles convey the virus 
to other cells. The virus causes hyaline degeneration in the tissues ; 
the hyaline degeneration in the walls of the blood-vessels causes them 
to rupture, producing hemorrhages. Oertel expresses the opinion that 
bacterial organisms cause diphtheria, and that they produce this result 
not by their direct action, but by producing a ptomaine which infects 
the system and causes the disease to be constitutional. The microbe 
itself is mostly confined to the surface, whereas the action of the virus 
is "widespread and deep." The most eminent pathologists of the 
present time do not express any more positive opinions in reference 
to the specific principle or germ of diphtheria than is contained in the 
above summary of Oertel's views. Dr. Pruden has made systematic 
study of a series of cases of diphtheria, which would seem to indicate 
that a streptococcus which is almost constantly present in the pseudo- 
membrane probably stands in a causative relation to the disease. 1 

Diphtheria occurs in all countries, at all seasons, but particularly 
during the colder months of the year. Overcrowding favors the exten- 
sion of the disease, especially the presence of large numbers of children 
in schools. Predisposing causes are bad hygienic surroundings, espe- 
cially filth, dampness, and poor ventilation. McCallom states, how- 
ever, that imperfect drainage and insalubrious conditions are not impor- 
tant in increasing the frequency of diphtheria, this disease having been 
found more prevalent in localities in which there was no fault to be 
found with hygienic conditions than in sections where the reverse was 



1 See American Journal Medical Science, 1889. 
(500) 



Diphtheria, 501 

the case. Children, especially the young, are more prone to the disease 
than adults. 

Sucklings are rarely affected; persons debilitated from any cause 
are liable to take the disease. 

"The immediate cause is universally admitted to be the bacillus 
discovered by Klebs in 1883, and obtained in pure cultures in 1884 
by Loeffler, who demonstrated its pathogenic importance. This bacil- 
lus, the Klebs-Loeffler, or diphtheria bacillus, is a slender rod, usually 
slightly bent in the middle, its extremities club-shaped, and tending to 
become more deeply stained than the other parts. The bacillus 
inclines to form groups of two to five, lying parallel; it is nearly as 
long and twice as broad as the tubercular bacillus; it thrives in milk, 
and grows readily upon the mixture of blood, serum, and bouil- 
lon recommended by Loeffler, colonies being formed in the incubator 
in the course of twelve hours before any considerable growth of associ- 
ated bacteria has taken place.- When kept in darkness in a moist 
state it lives for months." - (Wood.) 

Morbid Anatomy. — In the catarrhal inflammation the mucous 
membrane of the tonsils, uvula, soft palate, and pharynx are swollen 
and of a dark-red color. Its surface is at times covered with a mucous 
membrane, which is sometimes opaque from the presence of abundant 
leucocytes. The tonsillar crypts may contain opaque, grayish-colored, 
or yellow material not projecting above the surface, and cells con- 
sisting of cells, granules, and bacteria. The catarrhal inflammation 
alone may exist, and the pseudo-membranous and gangrenous inflam- 
mations are usually associated with the catarrhal variety. The appear- 
ance above described is not to be distinguished from those occurring 
in non-diphtherial varieties of sore throat and in lacunar or follicular 
forms of tonsillitis, except by the bacteriological examination. 

The pseudo-membranous sore throat of diphtheria affects the upper 
surface of the soft palate, to the nostrils, pharynx, and larynx, even to the 
trachea and bronchi ; the bacilli may be found upon the conjunctiva 3 , 
upon the genital mucous membranes, and upon wounded surfaces of 
persons affected with diphtheria. These first appear as spots or patches 
of a grayish-white, and surrounding the gray patch is a yellowish or 
cream-colored border, changing from this to a yellowish-brown, then 
into a very darkish-brown as the disease progresses. 

The pharyngeal inflammation may extend into the Eustachian 
tubes, while its continuance is frequent into the larynx, trachea, and 
bronchi. Above the vocal cords the false membrane is intimately 
adherent to the mucous membrane, but below these cords it is generally 
but loosely attached, and often lies upon the inflamed mucous mem- 
brane. In the trachea it is apt to form a hollow cylindrical cast of 
this tube. The same is true of the larger bronchi. The lungs are 
usually distended, injected, and contain numerous patches of lobular 
atelectasis and nodules of broncho-pneumonia. The lymphatic glands 
beneath and behind the jaw are enlarged. The spleen is enlarged, 



502 Diphtheria. 

also the kidneys; the capsules of the kidneys are readily detached; 
the surface is at times speckled with extravasated blood. (Fitz.) 

Symptomatology. — The especial feature suggestive of diphtheria 
is the formation of a false membrane. This appears first as grayish- 
white patches, often formed in the course of a few hours, and rapidly 
increasing in size. The symptoms of diphtheria may arise in two or 
more days after exposure. Pain in swallowing is an early symptom, 
accompanied by fever. The fever may be preceded by a chill. The 
temperature usually rises from 102 degrees to 104 degrees Fahrenheit, 
and the inflammation (dysphagia) may be slight or considerable. The 
higher the fever, the more probable the occurrence of headache, back- 
ache, loss of appetite, and weakness. The patches, it is to be remem- 
bered, may be present on the soft palate, or in the pharyngeal pouch. 
As the disease progresses, the patches coalesce, and extend to the uvula 
and soft palate, and in children with large tonsils the voice becomes 
thick, the lymph glands moderately swollen and sensitive, and the urine 
is likely to contain a small degree of albumin. 

The severe cases of diphtheria are more conspicuous in character 
because of septic symptoms. The temperature may be high, 104 
degrees Fahrenheit at outset, or rise on the third or fourth day. It 
may, however, be only moderately elevated, or even subnormal. The 
pulse is rapid and weak, corresponding to the range of the tempera- 
ture. The patient may be delirious, and have no appetite. Vomiting 
and diarrhea are frequent. The breathing is slow, or perhaps rapid 
and noisy, and the voice is hoarse. A thin acrid discharge flows from 
the nostrils, producing sores or crusts on the lips. The mouth is 
usually open, the tongue dry and fissured. The false membrane is 
found throughout the pharynx, either diffused or in patches, and forms 
a thick, opaque, yellow cyst resembling washed leather, or it may be 
a dark-brownish color. In the gangrenous cases the pseudo-membrane 
patches become green or brown, are moist and shreddy, and of a very 
offensive odor. Hemorrhages from the mouth and nose are frequent 
and sometimes considerable, and they may also occur in the skin. 

In severe cases of diphtheria as it progresses, there are suffocating 
symptoms, and septicaemia. 

Croupous symptoms may develop suddenly or gradually. When 
the symptoms of septicaemia are prominent, the prostration of the 
patient is extreme, and swallowing is difficult, due largely to paralysis 
of the soft palates. It may be necessary to feed the patient through 
a stomach-tube. The pulse is weak and irregular, and the heart sounds 
are faintly heard. Death may occur suddenly and unexpectedly from 
cardiac paralysis even during apparent convalescence. 

Diagnosis. — The earlier the diagnosis is made, the more important 
it is, so that proper remedial measures may be employed at the begin- 
ning, as well as measures designed to prevent the spread of the dis- 
ease. In a large proportion of cases the diagnosis is easy after diph- 
theria has continued twenty-four hours, since, in addition to the fever, 



Diphtheria. 503 

and pain in swallowing, the characteristic grayish-white patches have 
begun to form, over one or both tonsils. In some cases the diagnosis 
is postponed for two or three days, because some children are not old 
enough to express their early sensations, so do not complain of pain. 
The diagnosis ultimately depends upon the discovery of the Klebs- 
Loeffler bacillus in a case of sore throat. In a locality where diphtheria 
is prevailing, the child's fauces should be examined by the attending 
physician, especially if there is fever, and often evidences are found of 
diphtheria which, without an examination, would not have been detected. 
In many cases it is impossible to make a diagnosis until the disease 
has been under observation some days, and its progress and the char- 
acter carefully noted, the difficulty in diagnosis arising from the fact 
that the membranous exudate is concealed from view. In nasal diph- 
theria the pseudo-membranous exudate is concealed from view; it may 
be located upon the superior and posterior portions of the Schneiderian 
membrane, and therefore, invisible, while the anterior and visible por- 
tions of the nares and facial surface are hypergeniic and secreting muco- 
pus in an abundance, but are free from the pseudo-membranous exudate. 

In laryngeal-tracheal diphtheria, diagnosis is not infrequently 
delayed in a similar manner. All cases of membranous sore throat, 
whether appearing as lucana tonsillitis, fibrinous, or diptheritic tonsil- 
litis, or pharyngitis, are, or should be, regarded as diphtheria until the 
bacteriological examination has denied the presence of the specific bacil- 
lus. Cases of membranous rhinitis are also reported to be regarded 
as nasal diphtheria unless the absence of the Klebs-Loeffler bacillus 
has been demonstrated. A pseudo-membranous inflammation of the 
throat, tonsils, soft palate, and uvula may occur in scarlet fever, mea- 
sles, typhoid fever, and in other infectious diseases. The membrane 
may present nothing by which it could be distinguished from diphtheria. 
The diphtheritic pharyngitis in scarlet fever mostly resembles that 
occurring in diphtheria. The fever is high and more continuous, the 
swelling is greater, the Eustachian tube is inflamed, and the eruption 
of this disease soon appears. In young children the tonsillitis accom- 
panied with exudation limited to the crypts or extending beyond them, 
whether false or not, might or might not be due to diphtheria. A bac- 
teriological examination will clear up the diagnosis. 

Prognosis. — The prognosis of diphtheria, like that of scarlet fever, 
varies greatly in different cases according to its type. In some epi- 
demics it is very mild ; in others it is very fatal. Between the mild 
and the most severe cases, attended by profound blood-poisoning, there 
is every grade of severity. 

The prognosis is usually favorable when the inflamed surface and 
pseudo-membrane are of little extent, the fever and swelling moderate, 
and the neighboring lymphatic glands and underlying connective tis- 
sue but little involved. 

Nasal diphtheria, which is commonly present in severe cases, and 
which produces an offensive, irritating, and highly infectious discharge, 



504 Diphtheria. 

always involves great danger. It is likely to give rise to systematic 
infection, by conveying the virus to the different parts of the sys- 
tem by the means of the lymphatics. If while the local disease is 
severe and extensive, the breath and exhalations become offensive, and 
the countenance and surfaces generally begin to have a dusky, pallid 
hue, profound blood-poisoning has occurred, and the patient will prob- 
ably die. 

The prognosis in any case of diphtheria is always doubtful, since 
the mildest cases may become severe, and the severe cases may improve. 
The prognosis among children (especially young) is looked upon as 
grave; sucklings, however, are rarely affected. Convalescence from a 
mild case of diphtheria usually occurs toward the end of the first week, 
while in septic cases the disease may continue for a period of two or 
three weeks. The range of temperature is less indicative of the degree 
of the toxaemia than are the extreme prostration, swelling of the lym- 
phatic glands, offensive discharges from the mouth and nostrils, and 
abundant albuminuria. Diphtheritic paralyses are usually recovered 
from unless respiration and circulation are conspicuously affected, and 
especially when there is paralysis of the diaphragm. 

Treatment. — The most efficient method of preventing diphtheria 
is isolation, and disinfecting the patient, the apartments, bedclothes, 
furniture, and prevention of all noxious gases, especially those ascend- 
ing from the sewers and from filthy accumulations of all kinds. The 
utmost care should be exercised to see that discharges from the mouth, 
nose, and bowels, and the urine, are at once thoroughly disinfected. 
(See Typhoid Fever.) Keep the room well ventilated, but allow no 
draughts, and the temperature of the room at about 70 degrees Fahren- 
heit, with the air thoroughly moistened by means of a teakettle boiling 
in the room. No one should enter the room except the nurses and the 
medical attendants, who should take the greatest care to avoid per- 
sonal infection from discharges and also the infection of others by 
carrying the poison upon their clothing. Thus the doctor and nurses 
should put on a linen duster, apron, or other similar garments when- 
ever they come to the patient, and disinfect themselves before leaving 
the house. Deaths have occurred to nurses from the lodgment of a 
piece of infected mucus in the eye or upon some abrasion during the 
local treatment. 

The efficacy of sulphur fumigation against infection has been 
denied and reaffirmed upon good authority, and observations, appar- 
ently made with accuracy and care, have been reported from time to 
time to prove both sides of the question; but at the present time the 
weight of the highest authorities in bacteriology is against its doubtful 
efficacy. Many bacteriologists have admitted that burning sulphur 
would kill bacteria, but not germs. 

Dr. Squibs states : "If there be no moisture supplied to the burn- 
ing sulphur in fumigating the apartment, that which was present in 
the air and in the surfaces of the chamber is soon used up, and the dry 



Diphtheria. 505 

gas remains indefinitely, in comparatively inactive and ineffective con- 
ditions. The dry, passive anhydrate would necessarily destroy all 
organisms which breathe in any degree, because breathing surfaces are 
moist. But in embryonic life protected by a shell, as in seed, if the 
shell is dry, the gas would be impotent." The above statement conveys 
very important information. It is so important that the specific prin- 
ciple of diphtheria should be destroyed wherever this disease appears 
in order to prevent its propagation, that any safe measures which would 
aid in producing this result should be employed in addition to sulphur- 
burning. Hence a vessel of water should be kept boiling in the cham- 
ber while the sulphur is being burnt. 

The tendency of the disease is usually toward exhaustion. The 
child should be kept as quiet as possible, and not be encouraged to play 
with toys during early convalescence. Whenever there are signs of 
cardiac failure, the horizontal position should be rigidly persevered in 
or enforced. Sustain the child with the most nutritious and easily- 
digested food, — milk, soft-boiled egg or egg-nog, soups thickened with 
mashed potatoes, tapioca, sago ; but other foods, such as sweetbreads, 
birds, and young chickens, should be used on occasions when the child 
is able to swallow easily. Alcoholic stimulants should be given when 
there is exhaustion. At first they should be given with the food and 
in moderate doses; in the later stage of the disease they should be 
employed more freely, both with and without food, as the case seems 
to indicate. 

Experience has shown that the only way of controlling the inflam- 
matory action of the throat is to destroy the bacillus; various means 
are used for this purpose. Ice is very useful; ice-cream is a pleasant 
mode of employing ice. Hot poultices to the throat sometimes subdue 
the inflammation to a little extent. A strong current of galvanism 
may act very beneficially in subduing the inflammation, relieving 
pain, and lessening the haste of the bacillus. It should be applied by 
means of a small nasal electrode, properly loaded with a bit of absorbent 
cotton dipped in peroxide of hydrogen sol., and carried through the 
nose (it may be dipped in ten per cent or six per cent sol. of cocaine 
before inserting in the nasal cavity) till it reaches the posterior part 
of the uvula. This pole is positive. If there is difficulty in passing 
it through the nose at first, when an obstruction is reached, apply the 
current, and give five to ten milliamperes for five minutes. The nega- 
tive pole is placed over the throat corresponding to the side being 
treated. If nasal treatment can not be given, then it may be applied 
through the tonsils externally, the same as for catarrh. (See article 
on Electricity.) The electricity, by its peculiar action, aids in clean- 
ing out the debris. It is of a solvent nature, and causes free secretion 
in the mouth and throat ; it renders the bacilli less active, and their 
clinging is temporarily destroyed ; hence the child is able to discharge 
it from the mouth. The seance should be mild internally and strong 
externally, and repeated every six or eight hours. After each seance, 



506 Diphtheria. 

spray the throat with a solution of peroxide of hydrogen. Between 
the treatments give the child ice-cold food. Leiter's tube or other ice 
receptacles should be kept applied to the throat, remembering to put 
a piece of flannel between the ice-bag and the throat. For cleaning 
out the nose, use a weak solution of sulphurous acid, alternately with 
peroxide or dioxide of hydrogen, from twenty to fifty per cent. Ato- 
mization with a saturated solution of boric-acid solution is prescribed 
by many physicians. 

There is nothing which will help to clean out the nose equal to 
galvanism. The nasal cavity should be kept cleaned out, and this it 
is often very difficult to do. The electricity aids wonderfully in 
relieving the congestion of the mucous membrane of the nose, enabling 
the child to discharge the mucus collected ; then, following the galvan- 
ism, an antiseptic spray may be used of hydrogen peroxide ; use a four 
or six per cent solution of cocaine in irritable cases ; it may be applied 
by means of a spray or absorbent cotton swab before commencing the 
galvanic treatment. Simple solutions of common salt, one per cent 
of carbolic acid, or a saturated solution of boric acid, have all been 
recommended. Loeffler recommends. a ten per cent solution of sodium 
sulphite, which may be used with satisfaction. In the case of adults 
the better plan is to introduce the nozzle of an atomizing syringe hori- 
zontally into the external nostril, and give a free injection with such 
freedom and force that, if possible, it shall force its passage through 
the other nostrils ; or in adults the nostrils may be cleaned out by throw- 
ing the spray of an atomizer into the posterior nose through the pharyn- 
geal opening. 

Astringents that are largely used for shrinking up the mucous 
membrane, are such as silver nitrate from six to twenty per cent solu- 
tion; perchloride of iron has been especially employed in various 
forms. Monsel's solution is a favorite; and it is less irritating than 
the chloride, and is said to be equally efficient. 

As solvents of the false membrane, animal ferments, such as pep- 
sin and trypsin, and vegetable ferments, such as papain, have been very 
highly recommended from time to time. They are entirely safe, pro- 
ducing little or no irritation. Lime-water has been much used, and it 
is thought that it acts as a solvent. Lactic acid is considered a very 
efficient solvent. Lennox Browne recommends the pure acid to be 
applied to the throat by means of a dense swab of absorbent cotton, 
with sufficient firmness of pressure against the mucous membrane to 
detach the edges of the membrane. The other astringents may be 
applied in like manner, such as the silver nitrate and the iron. 

In the first stages, germicides have been used with the view of 
destroying the bacillus. The small spots of membrane are carefully 
touched with a concentrated carbolic acid ; later, glycerine, containing 
three to ^ve per cent of carbolic acid, may be used upon large, diffused 
surfaces. Loefner's solution, which is composed of ten grams of men- 
thol diluted in thirty-six cubic centimeters of toluol and added to four 



Diphtheria. 507 

cubic centimeters of liquor ferri sesquichlorati (Br. Ph.) and sixty 
cubic centimeters of absolute alcohol, has been much used abroad, 
applied in full strength by the swab or diluted by atomization. 

The biniodide of mercury is to be preferred to corrosive subli- 
mate, because it does not precipitate serum albumen, and is, therefore, 
more penetrating; it is also less apt to undergo decomposition. Mer- 
curial preparations should be applied by means of some sort of an 
atomizer, and a known quantity of the mercurial should be thrown into 
the throat, so as to avoid any possibility of giving too much of it, espe- 
cially when calomel or corrosive sublimate is being given for its gen- 
eral effect. 

There is no known specific drug for diphtheria. Some writers 
say that chloride of iron has no influence upon the disease, neither 
does potassium; chloride has no control over the bacillus, it being 
largely eliminated by the saliva, and is not sufficiently germicidal to 
be of value. The tincture of the chloride of iron seems to us, how- 
ever, to be indicated for its tonic effects if nothing more, inasmuch as 
the bacillus is a destroyer of the red blood corpuscles, and its influence 
upon the kidneys would be beneficial. It should be given, if at all, 
in small doses at short intervals in a little glycerine and water. Cal- 
omel and soda rubbed together, or calomel simply, has for the last 
few years been largely used as a dry powder for its local effect ; it should 
be given in the beginning of the attack, and in doses ranging from 
one-quarter to one-half grain every two hours until free purgation is 
produced ; and later on in the disease, if the constitution will permit 
it, that is, if there is no depression, the calomel may be repeated, as it 
seems to aid in loosening up the false membrane. If corrosive sub- 
limate is preferred, one seventy-fifth of a grain may be given every two 
hours to a child two years of age ; at six years one-fortieth or one-fiftieth 
of a grain, according to the constitution of the patient ; at ten years 
of age one-thirty-fifth of a grain. Pilocarpine has been employed to a 
considerable extent on account of its causing free secretion in the mouth 
and throat, and thereby loosening the false membrane. Some authors 
object to its use, because too free 'secretions are provoked by its use, 
filling up the bronchial tubes so as to interfere with respiration. 

Stimulants, — alcohol, strychnine, digitalis, and strophanthus, — 
are of great value. 

Nasal hemorrhage often occurs in case of nasal diphtheria. A 
small roll of absorbent cotton, saturated with a fifty per cent solution 
of dioxide of hydrogen, may be used to plug up the nasal passage. 
When the fever temperature reaches 102 degrees Fahrenheit in diph- 
theria, the patient may be sponged with tepid water gradually cooled 
down by adding cold water. If this fails, cold packs or the bath may 
be employed. The bath temperature should be started at 90 degrees 
Fahrenheit, and gradually reduced as low as 70 degrees Fahrenheit if 
necessary. It is important that the treatment be no more severe 
than absolutely required for the reduction of temperature, and when 



508 Diphtheria. 

the thermometer in the mouth or in the rectum indicates 100.5 degrees 
Fahrenheit, the patient should be taken out of the bath. In feeble 
cases the hot-water bag is put to the feet during the bath. 

Turpentine has been highly recommended by physicians of expe- 
rience, when used locally as well as internally, for its prompt action 
in arresting the formation and extension of the pseudo-membrane, and 
as an antidote to the diphtheritic virus. Dr. Rewentauer states that 
an infant of two years, treated by other remedies, began to have symp- 
toms indicating invasion of the larynx on the fourth day. Tracheotomy 
was resolved upon, but previously trial was made of pure turpentine 
in a teaspoonful dose. The croupiness ceased, other symptoms 
improved, and the patient recovered without tracheotomy. 1 Rose, of 
Hamburg, "employed turpentine in teaspoonful doses mixed with 
spirits of ether (ether one part, alcohol three parts), three times daily. 
A teaspoonful of a two per cent solution of salicylate of sodium was 
also given every two hours. Under this treatment the temperature 
and the pulse diminished, other symptoms improved, and in fifty-eight 
cases thus treated by Dr. Rose ninety-five per cent recovered." 2 Eigel 
also employed turpentine in teaspoonful doses in forty-seven cases, in 
fourteen of which the question of tracheotomy arose. A manifest 
reduction of temperature followed the use of the turpentine. The 
percentage of deaths in all thus treated was 14.9, while of those treated 
by corrosive sublimate, salicylic acid, potassium chlorate, etc., 32.5 
per cent died. Dr. Llewellyn Eliot also reports good results from the 
vaporization of turpentine. 

The above use of turpentine in diphtheria will be of great inter- 
est 1x> mothers. It is a praiseworthy domestic remedy, properly used. 

The prolonged inhalation of the vapor of the oil of turpentine, 
which has been so much employed, is prescribed as follows: it is 
mixed with water in the proportion of two tablespoonfuls to one quart 
of water. 

1$: Acidi carbolici, ol. eucalypti, aa 3j 

Spirits turpentine |viii 

This is placed in a shallow vessel or vessels with a broad surface, 
and maintained in a constant ebullition or simmering, upon a gas or 
other stove. The vapor, which is not unpleasant, soon nils the room 
and the adjoining rooms. As regards the effect on the patient, the 
turpentine vapor passing over the inflamed surfaces, which are the 
seat of the exudate, with every inspiration probably produced more or 
less local disinfection, apart from the systemic disinfection which it 
may cause by entering the blood and the tissues generally. Thus 
employed, the turpentine is also apparently a useful domiciliary disin- 
fectant, affording protection in a measure to other members of the 



'Centralbl F. Klin. Med. 
2 Therap. Monastchr. 



Diphtheria. 509 

family. The solvent agents heretofore most largely prescribed are 
combined in the following prescription: — 

\y. 01. eucalypti 3ij 

Sodium benzoat 3j 

Glycerine sij 

Sodium bicarbonate. . 3ij 

Aquae calcis (lime-water) oj 

Mix. 
To be used freely with the hand atomizer from three to five min- 
utes every half hour, or with the steam-atomizer almost constantly. In 
very young children the throat may be mopped out, using a fresh mop 
in each application. Swab four or five times at each treatment, hence 
it will take as many fresh swabs at each treatment. This alkaline 
spray not only exerts a solvent action on the pseudo-membrane, but 
also renders the muco-pus thinner, less viscid, and therefore so changes 
its character by diminishing its viscidity that it is more easily expec- 
torated. 

Antitoxine Treatment. — In 1890, Behring and Kitasato published 
their first article upon the use of blood-serum of artificially-immunized 
animals in the treatment of diphtheria. After their third publication, 
in 1892, the subject attracted widespread attention, and became a mat- 
ter of clinical investigation by Roux and others. Nevertheless, the 
chemical theory that the antitoxine directly neutralizes the toxine still 
has advocates. The antitoxine, as some authors state, has no direct 
bacteriological effects, although it arrests the spread of the local inflam- 
mation and the growth of the bacillus, probably by preventing the tis- 
sues from being so poisoned by the toxine that they are unable to resist 
the bacillus. It is proved that it requires a definite quantity of the 
antitoxine to neutralize the effects of a definite quality of toxine. 

As it is said to be impossible to know how much toxine is present in 
a diphtheritic patient, the dose of antitoxine is uncertain and empirical ; 
the older the patient, the longer the duration, and the greater the 
intensity of the disease, the larger the dose required. Certain untoward 
effects may follow its use ; rarely a local abscess is formed, but diffused 
erythema, rheumatoid swelling of the joints, general uticaria, and 
albuminuria have been noticed in a number of cases, — effects suffi- 
ciently serious to make it wise to repeat the small or moderate dose of 
antitoxine if necessary, rather than in the beginning to give an over- 
whelming amount. 

- The unit of dose generally received is that of Behring, one cubic 
centimeter of so-called normal serum, 1 which is of such strength that 
one cubic centimeter will overcome ten times the minimum dose of 
diphtheritic poison fatal to a guinea-pig. The ordinary dose of the 
serum, which should be injected into the buttock, or flank, is 600 anti- 
toxine units. If by the next day there has not been marked improve- 
ment, 1,000 units may be given. In very severe cases, or when the 
patient is not seen until late in the disease, from 1,000 to 2,000 units 



510 Diphtheria. 

may be administered at the first dose. In successful cases the effects 
of the serum are apparent within a few hours in the subsidence of the 
fever, the slowing of the pulse, and the reduction in the severity of the 
local symptoms. Inside of twenty-four hours the membrane should 
begin to disappear. 

Although it is said that the exact power of the antitoxine treatment 
can hardly be considered to be determined, yet certainly its value has 
been so far proved that it should be used in every case of diphtheria 
with as much positiveness and determination as quinine would be 
employed in malaria. In the statistics collected by Welch, embracing 
many thousands of cases, the mortality was reduced by the use of the 
antitoxine about half. In the Paris hospitals from 1888 to 1889 the 
yearly average of deaths from diphtheria was 1,840. In 1890 there 
were'l,668 deaths; in 1891, 1,361; in 1892, 1,403; in 1893, 1,266; in 
1894, 1,009 ; and in 1895, 435. The total death-rate thus fell after 
the introduction of the serum treatment to about one-fourth of what it 
had been for many years, and to one-third of the average for the pre- 
vious five years. Although it is certain that serum treatment fre- 
quently fails, yet if some of the treatment is begun on the third or 
fourth day, the mortality is thirty-six per cent greater than in cases 
treated on the first or second day, and three and a quarter times less 
than in cases treated after the fourth day. In our opinion the sooner 
the practitioner begins the antitoxine treatment the better, that is, when- 
ever a true feature of the case warrants the diagnosis of diphtheria, 
without waiting for the confirmation of this diagnosis by bacteriological 
methods. There is no reason for believing (as history states) that the 
antitoxine has any direct sedative influence upon the heart or irritative 
influence upon the kidneys, and certainly by arresting the diphtherial 
process it has a great tendency to prevent complications and secondary 
effects. In laryngeal diphtheria with stenosis, requiring operation, 
there is sufficient accumulated experience to show that the serum is a 
very valuable agent in preventing the progressive development of the 
false membrane in the false tubes, and that in many cases in which 
intubation would be otherwise insufficient, the antitoxine treatment does 
away with the necessity of tracheotomy. The value of antitoxine as an 
immunizing agent has not been chemically determined, although guinea- 
pigs may be rendered completely immune. 

ir The serum used that will supply 600 to 1,400 antitoxine units in a volume of 10 
cc. is necessarily from sixty to one hundred and forty times as strong as normal 
serum. (Wood.) 



CHAPTEK XXXIV. 

CAUSES OF EAK TKOUBLES IX CHILDKEX. 

The commonest causes of aural diseases in children are acute 
exanthemata, acute and chronic catarrh of the nares and naso-pharynx, 
diphtheria, diseases of the heart, and hereditary syphilis ; in older chil- 
dren, typhoid fever will cause ear trouble. Scarlet fever affects many 
more than do measles and diphtheria. Caries, or ulcerative ostitis 
(Schwartze), attacks the petrous bone most frequently of all the cranial 
bones. It is usually the result of an acute or chronic suppuration 
of the soft tissues of the ear which has extended to the adjacent bone. 
(Keating.) Caries of the temporal bone often heals without much 
loss of hearing if the labyrinth has escaped the attack ; the fatal results 
of caries and necrosis usually are due to purulent meningitis, abscess 
of brain, phlebitis of the sinuses, with pvrsemia, or to a combination 
of them all. (C. H. Burnett, M. D.) 

INFLAMMATION AND ITS KESUXTS. 

Erythema, eczema, and intertrigo of the auricle are common in 
early childhood. Syphilitic lupus, pemphigus, and congenital ichthy- 
osis are often seen in the auricle. Eczema, the most common affec- 
tion of the skin, attacks the auricle, in both the acute and the chronic 
form. If allowed to become very chronic, it may permanently thicken 
and discolor the auricle. The matting of the hair about the auricle 
aggravates the disease; the hair should be cut close or shaven. This 
skin disease is often due to disorders in the child's digestion; but in 
most cases the disease is greatly aggravated by local irritation and 
scratching or rubbing from the patient's fingers. 

Very often wearing a cap leads to maceration of the baby's 
auricle and the side of the head behind it. 

Intertrigo, or chafing, is the first step, and then eczema. Even in 
this first stage, the parts should not be washed with soap and water, 
nor even with water alone. The parts affected may be smeared with 
bland sassafras or quince-seed mucilage, or sprinkled with a powder 
composed of equal parts of oxide of zinc and starch. The pellicle, 
or crust, which this forms with the secretions from the eczematous 
skin, should be allowed to remain, as it protects the inflamed skin and 
favors healing. If in the more chronic form the yellowish crusts of 
hardened serum get very thick, and must be removed, then soften with 
sweet-oil and gently remove them; but avoid this in the acute stage. 
In acute eczema the skin must be protected as in burns. It is char- 

(511) 



512 Cause of Ear Troubles in Children. 

acterized by heat, burning, and tingling, with redness and oedema, 
which latter may be considerable where the skin is lax ; shortly papillae 
and vesicles, which may appear on the epidermis, may be stripped off, 
leaving a raw, exuded surface, or the process may remain erythematous 
to the end. If the eruption of the acute eczema is protected, or is not 
irritated, it tends to subside in a few days; but not completely, for 
the eruption lingers in a less acute condition, and is apt to pass into 
subacute eczema, which is a less inflammatory condition with a red- 
dened itchy surface and moderate thickening. The diseased portions 
may be moist, tending to become scaly or crusted, or they may be 
hard and papular, exuding a glairy fluid when scratched. 

A skin disease of the child's auricle must be treated with caution. 
The various applications to the diseased skin of the external ear must 
not be allowed to clog the external auditory canal nor to run down 
upon the drum membrane. 

Boxing the ears, pulling the ears, and swabbing the canal for 
imaginary wax and dirt must be most carefully avoided. Boxing the 
ears is apt to produce rupture of the drum membrane, by the force 
of the column of air driven suddenly against it. 

Pulling the ears is nearly as injurious as "boxing" them, since 
the attachments of the auricle to the auditory canal are of such a nature 
that traction upon them is communicated to the sensitive fundus of 
the canal, and even to the membrana tympani. Hence pain and injury 
are often the result of this rude manipulation of the ear. (Sexton 
and Pinkerton.) 

FOREIGJS" BODIES IN THE EAR. 

This is a subject of great importance to general practitioners, as 
they are usually called first to see the child who has something in the 
ear; and afterwards the specialist's aid is invoked. 

Let it be written at the outset in most emphatic language that the 
mere entrance of a foreign substance into the ear is, in itself, of very 
little importance. In no case has injury to the child ever arisen from 
the mere presence of a foreign substance, like a bead, a seed, or a but- 
ton, in its ear. It is the unskilful, rough, and lacerating efforts made 
for its removal which has invariably produced the real injury. (C. H. 
Burnett. ) 

ISTo one but an aurist of experience should ever touch an ear with 
any kind of metallic instrument, even of the most delicate and spe- 
cial form. If there is a small bead or seed in the ear, a few syringe- 
fuls of warm water will bring out the foreign substance. 

When roaches, fleas, or insects of any kind get into the ear, a 
few drops of sweet-oil or linseed-oil will smother them, and relieve 
the suffering caused by their movements. Wash or syringe the ear 
with warm water in all cases of foreign substances entering into the 
ear. 



Cause of Ear Troubles in Children. 513 

I have known instances of maggots getting into the ears of chil- 
dren affected with otorrhoea. If such an accident occurs, a drop or 
two of chloroform or ether will destroy a maggot's life instantly, 
whereas syringing the ear with warm water only makes the maggots 
more lively, and pain in the ear more intense. Wax rarely accumulates 
in plugs in a child's ear to such an extent as to interfere with hearing. 
Syringing with warm water is all that is required for its removal. 

Accumulations of wax in the ear may be softened by using five 
or ten drops of the following : — 

5: Soda bicarb gr. xx 

Glycerine 3j 

Water 3 viii 

Mix. 

Apply warm to the ear. A dropper may be used for applying it. 
Now and then these accumulations are found in the ears of children 
from five to ten years old, — hard, leathery, or horny plugs, composed of 
epithelium with a little cerumen in the outer end, near the meatus. 
These plugs quite fill the canal, and render the ear totally deaf. Their 
removal is tedious, and can be accomplished only after continued use 
of the above-named solvent drops and patient syringing. 

Syringing tine Ear. — In syringing the ear of an adult or a child, 
but especially an infant, the nozzle of the syringe must be larger than 
the meatus of the ear, in order to prevent the entrance of the instru- 
ment into the canal. The ear syringes made with a nipple-like pro- 
longation of the nozzle are dangerous to use, as they can be made to 
enter the meatus half an inch or more, and can reach and wound the 
membrana tympani. The ordinary hard-rubber enema syringe is 
within reach of all, and is a safe syringe to use. With it an ounce 
or two of warm water may be thrown into an infant's or a young child's 
ear, and the return current caught on a towel held closely under the 
ear. If the accumulation of wax can not thus be removed, a specialist 
should see the child, — the best specialist, or one qualified to treat it. 
All fungus growths, as aspergillus, a variety of mould, may grow in 
the fundus of the ear upon the membrana tympani underneath the 
accumulation of wax; such cases should have early attention. A 
powder composed of salicylate of chinoline, one to sixteen parts of 
boric acid, blown into the ear after the wax is removed, will destroy 
the aspergillus. One application is usually enough. 

OTITIS EXTERNA DIFFUSA. 

This name is applied to the diffuse inflammation attacking the 
skin of the auditory canal as a result of the irritation arising from the 
ingress of improper medicaments, cold air, or cold water, from picking 
and swabbing the ear, or the continued presence of the fungus asper- 
gillus. Direct violence, such as putting snow into the ear in rude play, 
blowing into the ear, or subjecting the child to sudden changes of tern- 

33 



514 Cause of Ear Troubles in Children. 

perature, is accountable for this disease in many cases. It is a very 
painful affection; and its tendency to involve the subcutaneous tissues 
and even the periosteal lining of the osseous part of the auditory canal, 
causes it to assume very often all the features of a periostitis. 

The skin rapidly becomes red and swollen, and, from its confined 
position in a cartilaginous and osseous canal, is thrown into several 
thick folds or ridges, which, uniting in the center of the canal, soon 
obstruct all view of the drumhead, and render the patient hard of hear- 
ing. Tinnitus is also complained of, as well as intense pain. Several 
days usually elapse with all these painful annoyances to the patient, 
before secretion sets in. Then the skin often exudes, at first from 
several points, a bloody serum discharges, followed in a day or two 
by one purulent in character. The quantity of serum discharged in 
such cases is often very copious, wetting a number of towels or cloths 
in the course of twenty-four hours. Sometimes the inflammation may 
extend to the membrana tympani, and involve it, so that perforation 
ensues and mucus is found in the discharges of the ear. 

Treatment. — In the first stages, the treatment is surgical. While 
the skin of the canal is swollen and tender, the best treatment is to 
make one or two deep incisions, down to the bone if necessary^ into the 
congested skin. This will often cut short the disease; but the method 
is painful. The next best means of relief is to apply a dossil of cot- 
ton moistened with the following mixture: — 

9: Black wash f3j 

Glycerine fej 

Or a fifteen per cent solution of ichthyol in water may be used. This 
application will abort the circumscribed furuncles and the diffuse form 
of otitis externa. If, however, suppuration is fully established, the 
ear must be gently syringed with weak salt and water, warmed, or with 
boric-acid solution, or with a two-per-cent solution of carbolic acid, 
or with plain warm water, then gently mopped with absorbent cotton; 
and, if the acute stage has fully passed, and the ear is no longer sensi- 
tive to touch, boric acid in fine powder, or boric acid seven parts and 
iodoform one part, may be insufflated. If the ear is thus cleansed once 
or twice daily while the discharge is copious, and then once a day or 
every second day as the discharge diminishes, the organ will soon heal. 
But all fats, oils, vegetable matter, and poultices must be kept away 
from the ear, at this time and at all others, as they produce breakdown 
and sloughing of the fundus of the canal. (C. H. Burnett, M. D.) 



CHAPTEK XXXV. 
MEASLES. 

Synonyms. — Rubeola, marbilli. 

Definition. — Measles is an acute, epidemic, contagious disease, 
characterized by a peculiar papular eruption, occurring usually on 
the fourth day of the attack, preceded by catarrhal symptoms and 
followed by slight desquamation. 

History. — This disease was described with smallpox by Khazer, 
A. D. 900, who undoubtedly recognized the difference between them. 
Before that date we have no authentic account of the disease. It 
continued to be confused with scarlatina and smallpox until 1670-74, 
when Sydenham and Morton declared the former to be a distinct dis- 
ease. XVhere civilization has not penetrated, the disease is unknown. 

Etiology. — Measles is due to a specific poison that has not yet 
been isolated. It is both epidemic and contagious. All authorities 
agree that it can not originate de novo. 

That it is epidemic is manifest from the fact that the disease 
is far more common during certain seasons or years than others. A 
community may be comparatively free from the disease for a time, 
when at length it will sweep over it like a cyclone, and but few will 
escape. A period of immunity will then prevail, lasting for a longer 
or a shorter time, when it will again make its appearance. 

That it is highly contagious no argument is needed to prove. It 
ranks with smallpox in this particular. The contagiousness begins 
with the catarrhal symptoms and continues until after desquamation. 
The contagious principle exists in the breath, the exhalations from the 
skin, the blood, the tears, the nasal and bronchial secretions, and in 
the urine and fecal discharges. The poison of the disease gains access 
to the system in the great majority of cases through the mucous mem- 
brane and the respiratory tract, the inspired air carrying the active 
contagious principle. The disease is equally prevalent in both sexes. 

Symptoms. — The period of incubation is about ten days, at the 
end of which time an abrupt rise of temperature to 102 degrees or 
103 degrees Fahrenheit, the first day, with or without chill, occurs, 
and characteristic catarrhal symptoms appear. There are pains in the 
head, back, and limbs, loss of appetite, and malaise. The conjunctiva 
becomes red and watery; there is frequent sneezing, with excessive 
nasal secretion, and nosebleed not rarely; laryngitis, tracheitis, and 
inflammation of the bronchial tubes frequently give rise to a trouble- 
some cough. Sometimes the cough is croupy, and the respiration 

(515) 



516 Measles. 

embarrassed from the swelling of the mucous membrane of the larynx. 
Occasionally alarming symptoms result from edema of the glottis. 
The throat is sometimes a little sore, but never as it is in scarlet 
fever. In many cases during the invasion, the hard and soft palates 
and the throat itself are very red and covered with minute spots or 
points, which are sometimes spoken of as an eruption upon the 
mucous membrane. Diarrhea occurs in a small proportion of cases, 
convulsions rarely. The fever that may have preceded the catarrhal 
symptoms increases in intensity with the development of these symp- 
toms, and the temperature usually ranges from 102 degrees to 104 
degrees Fahrenheit. 

Stage of Eruption. — About the fourth day, when the catarrhal 
symptoms have reached their height, is usually marked by the devel- 
opment of the eruption, which first appears upon the forehead, tem- 
ples, and cheeks, and around the mouth, soon extending to the face, 
breast, extremities, and trunk. It appears at first in the form of 
minute red spots ; these rapidly increase in size and number, and 
become distinctly papillar and perceptible to the touch. When fully 
developed, the eruption is of a dark-red color, and in many cases is 
surrounded by areas of skin of normal color; but on certain portions 
of the body, especially the face, neck, and fore-arms, they are confluent, 
and these portions present a peculiar blotched and swollen appearance. 
Under the pressure of the finger they lose their color, but it returns 
again immediately upon removal of the finger. In from thirty-six 
to forty-eight hours, in favorable cases, all the symptoms begin to 
decline, and in from three to six days the fever has disappeared, des- 
quamation has commenced upon the face, and a rapid convalescence 
has been entered upon. In other cases, although the eruption rapidly 
fades and the fever subsides, yet a bronchitis remains for some days, 
and is the last symptom to disappear. As soon as the active symp- 
toms disappear, the appetite and natural disposition of the child return, 
and the patient is soon in ordinary health. 

There is also an abortive form of the disease in which the erup- 
tion appears with the ordinary symptoms, but fades away immediately, 
with a rapid abatement of the fever and a well-developed convales- 
cence by the fifth day of the disease. These cases are at once dif- 
ferentiated from those in which there is a sudden retrocession of the 
eruption by the immediate abatement of the constitutional symptoms. 

Among the malignant forms of measles are those cases in which 
the disease is complicated with some other serious illness, as in case 
of tuberculosis, typhoid fever, diphtheria, or scarlet fever. The dis- 
ease is frequently irregular under these circumstances ; the eruption 
is imperfectly developed, the fever high, and the complications exces- 
sive. A form of measles which has been seen in the army and in 
children's asylums, is that in which in the beginning there is violent 
dyspnoea with marked cyanosis and usually rapid death from asphyxia. 
In many of the cases will be found fine disseminated rales of a capil- 



Measles. 517 

lary bronchitis; but sometimes the only departure from the normal 
to be made out is extreme feebleness of the respiratory movements. 
It is to this variety of measles that the name of epidemic capillary bron- 
chitis has been given. 

In the adynamic form of measles the severe symptoms usually 
develop at the time of the appearance of the eruption. The pulse 
becomes very rapid, the respiration exceedingly hurried, and the tem- 
perature rises to 104 degrees or 105 degrees Fahrenheit. The tongue 
is dry, and typhoid face, great muscular prostration, and other symp- 
toms of the typhoid state rapidly develop. In young children, repeated 
convulsions are frequent, and often end in coma. In adults, delir- 
ium, mild and muttering or fierce and maniacal, comes on. Death 
in such cases may occur in three or four days ; or with the development 
of natural sleep, and a great increase in the secretion of urine, the 
violence of the symptoms may abate. In some of these the disap- 
pearance of the eruption is sudden, with a great increase of the symp- 
toms. "Black measles" is a rare form, with hemorrhage under the 
skin and the mucous membrane, and is usually fatal. 

Complications. — The most common complications of measles are 
the inflammations of the mucous membranes. These inflammations 
exist to a greater or less extent during the natural course of the dis- 
ease, and are not properly complications unless so intensified as to 
give rise to graver or dangerous symptoms. Violent nasal catarrh 
may give rise to a serious otitis media ; laryngitis with swelling may 
produce laryngeal obstructions; while actual membranous exudation 
is not very rare in the throat and larynx, and may be associated with 
the diphtheritic bacillus. Bronchitis is a very common complication, 
is almost universal, and is especially prone to pass into the smaller 
tubes and produce a capillary bronchitis, followed by infiltrated patches 
throughout the lungs, which, by their confluence, may produce wide- 
spread pneumonia. Broncho-pneumonia occurs. The pulmonary com- 
plications may develop at any period of the disease, but are more fre- 
quent and severe during the stage of the eruption and also during 
convalescence. A rapid respiration and dyspnoea, with increased fever, 
are their characteristic marks. When severe pulmonary complications 
occur in young children, the dyspnoea is extreme, and convulsions are 
not uncommon; death from suffocation may occur during the second 
or third day. 

In healthy subjects the conjunctivitis rarely ends in suppuration 
or any serious trouble. In delicate children suppurative conjunctivi- 
tis, diffused purulent keratitis, and ulceration of the cornea are espe- 
cially common. 

Stomatitis is a common complication, varying greatly in severitv. 
It may range from a simple inflammation to ulceration, or even to 
cancrum oris. Gangrenous inflammation of the mouth, however,, more 
frequently appears as a sequel than as a complication. 



518 Measles. 

Diagnosis. — During the stage of invasion it is difficult to dis- 
tinguish measles from a severe attack of coryza or bronchial catarrh. 
Known exposure to the disease would be the strongest evidence of 
its real character. After the appearance of the eruption, we may con- 
fuse the disease with rubella, or German measles, scarlet fever, vari- 
ola, varicella, or typhus fever. 

In rubella the catarrhal symptoms are slight, and the eruption 
appears within twelve to twenty-four hours after the invasion. The 
patient is not considered sick until the eruption is discovered. The 
temperature does not run high, the pulse is less rapid, and the dis- 
ease runs a shorter and milder course. 

The differential diagnosis between measles and scarlet fever is 
based upon a shorter period of invasion in scarlet fever, the presence 
of sore throat, the absence of catarrhal symptoms, and the difference 
in the appearance of the eruption. 

Measles is undoubtedly more frequently confused with variola 
than with any other disease. These are catarrhal symptoms in vari- 
ola, but not so marked as in measles. During the first twenty-four 
hours of smallpox the eruption often resembles very closely that of 
measles; but if there is any uncertainty, a delay of a few hours will 
usually make the diagnosis clear. A very important consideration 
in the differential diagnosis is the fact that in case of smallpox (vari- 
ola) with the appearance of the eruption all the active symptoms 
abate. The pain in the back, the head, the high fever, all disappear, 
but not so in measles. In variola the eruption soon becomes more 
markedly papillar, presenting a shotty feeling when the hand is passed 
over the surface. In the course of the disease the papillae become 
vesicles, and then pustules. In measles the eruption remains pap- 
illar throughout the whole course, and these papilla? are slightly ele- 
vated above the surface. 

Prognosis. — The prognosis will depend greatly upon the previous 
state of health of the patient, the surroundings, and the care and atten- 
tion the patient will receive. Careful nursing is highly important 
during the entire course of the disease, and during the convalescing 
stage care must be taken to avoid exposure to cold. In some epi- 
demics the death-rate of measles is much higher than in others, and 
the tendency to fatal complications much greater. The prognosis is 
favorable in those cases that pursue an even and regular course; but 
all cases of great severity bordering upon malignancy, or that pursue 
an irregular course, or that develop complications, should be most 
carefully guarded. The development of diphtheritic pharyngitis adds 
greatly to the danger, and the prognosis is generally unfavorable. Race 
is a characteristic of importance. Death is said to be much more 
frequent among the negroes than among the whites. In North Amer- 
ica, South Africa, and Oceanica, half the population of a whole dis- 
trict has died in the course of a few weeks. 



Measles. 519 

The continuance of high fever after the disappearance of the 
eruption is generally an unfavorable indication, denoting, as it does, 
the presence of some complication. 

Treatment. — The treatment of measles should be preventive, 
hygienic, and therapeutic. 

Preventive treatment refers to prompt isolation of the patient 
on the first occurrence of the catarrhal symptoms, thorough disinfec- 
tion of the apartments and all clothing, and the use of antiseptics 
applied to the body of the patient in the form of ointments. In cases 
of known exposure the well children who have not been exposed may 
be sent away from home, or the patient may be kept in some distant 
room in the house. The attendant should not mingle with the family 
without disinfecting herself and changing her clothing. (See Typhoid 
Fever.) During the illness antiseptic solutions may be applied to 
the body of the patient two or three times daily, thus preventing the 
diffusion of the poison. Carbolized oil and cold cream or vaseline 
with carbolic acid may be employed. 

The hygienic treatment is of great importance in measles. The 
patient should be placed in a large, well-ventilated room, which should 
"be shaded from bright light, but not completely darkened, and the 
temperature of the room should be uniform. The covering should 
not be too heavy, but light and comfortable, and an abundance of 
water should be given when the patient is thirsty. It is a mistake, 
too frequently made, to bundle a child up in heavy blankets and give 
nothing but hot drinks. When the eruption is tardy, a warm bath and 
an occasional drink of hot lemonade may be useful. Little food except 
milk is required, especially the first few days, and other foods that 
are given should be such as can be easily digested. 

As to therapeutic treatment in an ordinary attack of measles 
very little medication is required other than the hygienic measures 
referred to above. There is no specific known remedy that will cut 
short the disease. The conjunctiva should be washed with boracic- 
acid solution three or four times a day, or as often as indications 
require it. The boracic solution may also be used in spraying or 
cleansing out the nose, and the throat gargled with a solution of chlo- 
rate of potash several times a day. Keep the bowels open with some 
mild laxative. Diarrhea should not be interfered with so long as 
it is only slight in degree ; if it is excessive, give bismuth subnitrate 
in five-grain doses, according to age. If the eruption is delayed, a 
mustard hot bath, two teaspoonfuls of mustard to a gallon of water, 
or a hot mustard foot-bath should be used. A sudden rise of the tem- 
perature, or even a very high temperature gradually attained, almost 
invariably indicated the coming on of bronchial or pneumonic irrita- 
tion, and calls, therefore, for counter-irritation and the appropriate 
treatment for bronchial or pneumonic symptoms. A temporary ele- 
vation is not considered grave; but if the fever continues of a severe 
pyrexia (103 degrees Fahrenheit), it is dangerous, and must be met 



520 Measles. 

by the use of external cold or of antipyretics. Phenacetine ranks 
first as being the best antipyretic, and antipyrine next. In no cases 
should large doses be given of either of these remedies. It is safer 
to reduce the temperature to 90 degrees Fahrenheit, which, if neces- 
sary, may be gradually cooled further, even as low as 80 degrees 
Fahrenheit. After removal from the bath (of from five to seven 
minutes) the patient should be rapidly dried, and if there be any 
failure of vitality, whisky should be given. 

Some soothing expectorant cough mixture is essential, alternat- 
ing with small doses of quinine. Small doses of ipecac may be given 
with potassium citrate, but stimulants and expectorants, such as 
ammonium chloride, terebene, or oil of eucalyptus, are soon demanded 
in all pulmonic complications of measles. Extract of ergot is recom- 
mended in reducing the congestion; and the free use of hot flaxseed 
poultices over the chest is of the utmost value. In cases of malig- 
nant measles, free stimulation has to be used from the beginning of the 
disease. Milk, eggs, and brandy, and beef juice are essential. If a 
patient is too weak to take a bath, sponge the patient once or twice a 
day, and thoroughly dry the skin to keep up its functional activity. 
It should be insisted that flannel be worn, however light in weight; 
if it irritates, a fine linen garment can be worn underneath the flan- 
nel. Especially should the chest, abdomen, and feet be protected 
against the cold. The same care should be given as during convales- 
cence from scarlet fever. 



CHAPTEE XXXYI. 
RUBELLA (ROTRELU), GERMAN MEASLES. 

Definition. — This is a specific, contagious, febrile disease, char- 
acterized by mild catarrh, and an eruption simulating measles; it 
occurs independently of the existence of measles or scarlet fever, and 
possesses characteristic symptoms in its incubation, invasion, erup- 
tion, and period of duration. Furthermore, it will reproduce itself 
only in those parts exposed to its contagion. One attack usually pro- 
tects from subsequent invasion, but will not afford immunity from 
either measles or scarlatina. Children are most susceptible. The pro- 
dromal symptoms are enlargement and induration of the cervical, sub- 
maxillary, auricular, and the suboccipital glands. At times other 
glands are affected; but suppuration never occurs. 

Etiology. — Rothelu, or rubella, although long confounded with 
other exanthematous diseases, is without doubt a distinct disease and 
directly contagious. It occurs, as a rule, most usually in epidemics, 
and is due to an unknown contagium, which is capable of being trans- 
ferred in fomites, clothing, etc., and is given off from cutaneous 
exhalations and from the breath of the patient from the period of inva- 
sion to well-advanced convalescence. 

Symptoms. — The invasion period of rubella is short, and marked 
only by slight fever, malaise, nervous disturbances, and some conjunc- 
tival catarrh. This stage of incubation is most difficult to decide 
positively, as symptoms are almost entirely absent in many cases dur- 
ing this time. This stage may be from seven to twenty-one days. 
The average, however, is said to be about fifteen or sixteen days. 
"Griffith considers this varying period of incubation to be of diagnostic 
value, thus differentiating from the fixed period of the measles." The 
eruption is said to be especially prone to develop during the night, 
and in more or less erratic ways. It may appear first on the face 
or upon the body all at once, or on the inner side of the arms, etc. 
Griffith notes symptoms recorded as follows: "Chilliness, languor, 
faintness, headache more or less severe, pain in the back and limbs, 
coryza, red and watery eyes, sore throat, cough, and occasionally a 
hoarse, husky voice. As illustrating the more severe symptoms of some 
of the first one hundred cases, we note a rise of temperature dur- 
ing this period. Many of the patients did not show a higher registra- 
tion of temperature than 100 degrees Fahrenheit, and varied from 
this point to 103 degrees Fahrenheit; nausea and vomiting, delirium 
and convulsions, and epistaxis in three cases." Other observers have 

(521) 



522 German Measles. 

noted marked prodromal symptoms during the stage of invasion. Two 
cases of hemorrhage of eyes and ears have been recorded by Priolean; 
convulsions, by Smith and others ; delirium, by Hardaway and Cuomo ; 
uticaria, by Cullingworth in four cases ; rigors, by Nymann, and dizzi- 
ness, by Squire; Mettenheimer notes fainting, and Balfour a croupy 
condition; Earle, Kingsley, and Thierf elder report prodromal rash; 
Cuomo, an erythema preceding the specific rash. 

Elevation of the rash above the skin has also been noted. It is 
more or less polymorphous in color, size, and form, as well as in dis- 
semination. Upon the trunk and especially upon places where there 
is continuous pressure, the spots may become confluent, while upon 
the hands and feet they are usually discrete. The eruption spreads 
rapidly, reaching commonly its full efflorescence and beginning to fade 
in from twenty-four to thirty-six hours, and disappearing entirely 
without desquamation in three days. Its color ranges from a pale 
rose to a deep red ; and while it varies greatly in its minute appearances, 
there are two typical forms, — one in which the spots are minutely 
papular, like measles, and one in which they are large, reddish plaques, 
suggesting scarlet fever. 

Usually there are no complications, and the cases pass rapidly 
to recovery. There is said to be a malignant form of the disease. 
Kronenberg, quoted by Llaasch, reports four deaths from bronchitis, 
pneumonia, and cerebral congestion after rubella. 

Diagnosis. — We have no diagnostic guide that can be considered 
positively characteristic, or pathognomonic symptoms by which we 
would isolate a single individual case of rubella. It is said that the 
eruption of rubella, or German measles, may exist without the enlarge- 
ment of the lymphatic glands, and the enlargement of the lymphatic 
glands without the eruption. In such cases known exposure to the dis- 
ease would be the means of determining a diagnosis. In our experi- 
ence the only affection which the disease resembles is measles, from 
which it is believed to be separated especially by the lymphatic enlarge- 
ment and tenderness, as well as by the mildness of the catarrh and 
of the general symptoms, and by the polymorphic character of the 
eruption. 

Treatment. — Rarely is other treatment required than simple nurs- 
ing. Treat on general principles any symptoms which may arise, and 
should be met. Particular care must be taken that the patient is not 
exposed to a draught, or sudden chilling of the cutaneous circulation. 
This must be our endeavor until all danger of complication has passed 
away. A large, airy room is required, with a temperature of about 
68 to 70 degrees Fahrenheit. A teakettle boiling on the stove in an 
adjoining room for the admission of steam to the room occupied by the 
patient, where there is a harassing cough, affords comfort to the patient. 

As in all the other eruptive fevers, the treatment at the onset should 
be expectant. Very little, if any, medical treatment is required. Put 
the child to bed in a well-ventilated but somewhat darkened room, with 



German Measles. 523 

all noise and unnecessary visiting prohibited. The little patient should 
be allowed to drink freely, if there is much thirst, milk well diluted 
with lime water, barley water, or lithia water, whey, or weak lemon or 
orange water flavored with glycerine. An occasional cup of tea made 
very weak, for flavoring a cup of hot milk and water, will frequently 
be of great advantage in bringing out the eruption. If there is head- 
ache, the head can be kept cool by cloths wrung out of camphor water, 
and a hot foot-bath, with a little mustard in the water, may be admin- 
istered. Should the child be restless, sweet spirits of nitre forms 
undoubtedly the best sedative, and may be given with sweetened water 
or added to the lemonade. Should the skin be dry and the child delir- « 
ious, a hot bath may be administered. A fever mixture may be given 
at intervals, such as the following : — 

Ijt: Tine, aconite rad 71|j 

Spirits ajtheris nitrosi |ss 

Lig. ammon acetatis, q. s. ad ,lij 

Mix. 

Dessert-spoonful every two hours, as needed. 

Give a dessertspoonful every two hours or oftener, as required, to 
a child five to ten years old. 

Should there be a tendency to intestinal catarrh more or less severe, 
the symptoms should be carefully watched, and, when treatment is 
indicated, small and repeated doses of Dover's powder and calomel, or 
calomel and bismuth and pepsin, may be administered. 

1£: Hydrarg. chlor. initis gr. ss 

Pulv. Doveri gr. vi 

Pulv. aromat gr. vi 

M. ft. chart., No. vi. 

Sig. : One to be given to a child every hour or every two hours, as 
required for a child one year old ; or the following may be used for 
catarrh of the intestinal tract: — 

Ijt: Hydrarg. chlor. mitis gr. j 

Bismuth subcarb grs. xii 

Pepsi ni sacch grs. xxiv 

M. ft. chart,, No. xii. 

Sig. : One powder to be given every two hours. 

The diet should receive careful supervision and be graded to the 
requirements of each case. Mild aperient mixtures should be ordered 
for the bowels as indicated, and the lungs carefully examined daily. 
As soon as a sense of oppression or tightness about the chest is com- 
plained of, hot poultices or fomentations should be applied. If a case 
is considered serious, a mixture of equal parts of chloroform and 
tincture of aconite root may be painted over the chest and lungs. When 
the cough becomes troublesome, it should be treated by the usual 
expectorant mixture. The following has proven beneficial for cough : — 



524 German Measles, 

1$: Ammonise muriat 3j 

Vin. ipecac flSij 

Tinctura opii eamph flSijss 

Syr. senegse. flovi 

Aquse q. s. ad fljiv 

Mix. 

A teaspoonful every two or three hours for cough. All patieuts 
presenting laryngeal complications must be subjected to constant steam 
inhalations, together with the applications of heat and moisture exter- 
nally over the larynx. Many cases will require, in addition, a general 
1 stimulating treatment, such as digitalis, carbolate of ammonium, wine or 
brandy, and liberal fluid nourishment frequently administered. An 
oleaginous preparation should be applied to the skin during the stage 
of eruption and desquamation, if there be any. It allays itching in 
the eruptive stage, and aids in the reduction of the temperature, and 
also in the prevention of contagion, as it may be by these fine scales 
that the contagion is carried. Either olive-oil, cocoa butter, or cold 
cream is beneficial for this purpose. 

Complications are to be treated as they arise. During convales- 

, cence much care should be used in guarding against colds. The child 

should be placed on tonics, such as quinine, iron, and cod-liver oil. 

Wampole's cod-liver oil for children has proven very useful in the 

writer's hands. 

Suitable clothing must be insisted upon, with flannel next to the 
skin. 



CHAPTER XXXVII. 
VAEICELLA (CHICKEJSTPOX). 

Definition. — Chickenpox is an acute, specific, infectious disease 
peculiar to infancy and childhood, characterized by a short febrile 
period and a vesicular eruption distributed over the whole surface of 
the body. The vesicles appear in successive crops, and disappear by 
desiccation in from three to five days, occasionally leaving permanent 
cicatrices. 

Etiology. — Varicella is a disease of infancy and childhood. 
Infants under the age of six months enjoy a certain immunity, but it is 
not so marked as in the case of scarlatina and measles. Various organ- 
isms have been isolated from lymph of the vesicles of chickenpox, and 
Bareggi asserts that "he has discovered an ovoid micrococcus which 
exists in the white blood-corpuscles, and whose cultures are capable of 
producing varicella in infants;" "whilst Pfeiffer has found an amoeba- 
like parasite in the vesicular lymph." Varicella is certainly distinct 
from all other diseases, and is entirely incapable of protecting from 
smallpox or other affections. 

Symptoms. — Varicella has a period of incubation from ten to 
fifteen days (and is more variable in this respect than variola or 
measles), followed by a period of invasion which in most of Steiner's 
inoculation experiments lasted four days, but which in the natural 
disease is ordinarily much shorter. The onset of the disease is first 
made known usually by the appearance of the characteristic rash. 
Mothers will rarely have their attention called to any symptoms pre- 
ceding the eruption, and it is very seldom that the physician is called 
until the formation of the vesicles is well under way. 

The eruption of the varicella generally appears first upon the upper 
half of the body, as upon the chest or upper part of the back. From 
the place where the eruption begins, it spreads rapidly over the body, 
face, hairy scalp, and extremities. The rash is most abundant upon the 
face, or upon the forehead and near the temples. The vesicles are 
brilliant, surrounded by a reddish areola, and varying in size from a 
tenth to a quarter of an inch. Especially when scratched by the child, 
they may leave distinct ugly scars. Eresh groups of the eruption may 
appear for several days, so that various stages of the pock coexist side 
by side. In cachectic cases the varicellar eruption is often purpuric, 
and may be ecchymotic ; even gangrenous ulcers sometimes result. 
During the eruptive stage there is generally a mild fever, with the 
usual symptoms of that condition. The fever may be ushered in with 

(525) 



526 Varicella. 

a slight chill or chilly sensations. The rise of temperature is rarely 
above 101 or 102 degrees Fahrenheit. The fever is remittent in type, 
with evening exacerbations; or the morning temperature may be 
normal, and a slight rise occur towards evening. Occasionally the 
fever may run high. Thomas reports a case in which it rose to 106.8 
degrees Fahrenheit, but quickly fell. The febrile period continues for 
two or three days, or in cases of successive crops of the eruption, the 
fever may continue longer. 

Very rarely the throat may be a little sore. The duration of the 
disease from the initial symptoms to the last falling off of the crusts is 
eight or ten days. 

In healthy children the disease does not show much variation in 
type. 

Mr. J. Hutchinson was the first to describe the dangerous form of 
the disease. Hutchinson states: "It is not confined to weakly, ill- 
nourished children, but is most common in them. It is no doubt con- 
nected with the curious tendency to spontaneous gangrene sometimes 
met with in other children." 

In gangrenous varicella the vesicles, it is said, instead of drying 
up in the ordinary way, become black and get larger, so that a number 
of rounded scabs, with a diameter of half an inch to an inch, are 
scattered over the surface of the body. If a scab be removed, it is seen 
to cover a deep ulcer; around it the skin is of a dusky-red color. All 
the vesicles do not take on the gangrenous action, so that we may find 
many varicellous scabs of ordinary appearance mixed up with the 
blackened crusts. "The gangrenous process often penetrates deeply 
through the skin to the muscles, but under some of the scabs the ulcera- 
tion is more shallow. These cases are very fatal." (J. Hutchinson.) 
Mr. Warrington Howard reported the case of a baby twelve months old, 
who weighed only six pounds and a half. The child was attacked with 
gangrenous varicella, and died in two days of pyaemia, with secondary 
abscesses of the lungs. 1 According to Dr. Crocker, gangrenous erup- 
tion does not always appear to come from the varicellous eruption, but 
occurs in parts not the seat of the varicellous rash. (London Lancet > 
May 30, 1885.) Hutchinson states that loss of sight may result, in 
these cases, from purulent erido-choroditis. 

C amplications. — Varicella has no complications that are directly 
dependent upon it. 

Various diseases, however, have at times been noted accompanying 
it. Among those that have been recorded are erysipelas, otitis, and 
peritonitis. Measles and scarlatina have been reported in this country. 

Sequelae. — Not infrequently after varicella an anaemic condition 
is left, which may continue, unless properly treated, for some time. 
Nephritis, pneumonia, pleurisy, and abscesses have been recorded. 

Diagnosis. — Special interest is attached, in the diagnosis of vari- 



'Disease in Children," p. 49, Eustace Smith, New York, 1884. 



Varicella. 527 

cella, to its clinical separation from variola and varioloid. The prompt 
recognition of the benign character of the disease is of great importance, 
both to the patient and to the community, as failure on the part of 
the physician to make a correct diagnosis may either subject a patient 
to an isolation made doubly disastrous by exposure to the infected 
air of a smallpox pest-house or hospital, or expose a community to 
the danger of widespread infection from various subjects. Either 
mistake is a grave one, and certainly would involve the physician in 
its disastrous results. 

Varicella can usually be distinguished from varioloid without 
difficulty by the absence of serious prodromic symptoms. 

1. The age of the patient attacked by the disease. 

As we know, smallpox attacks all persons, regardless of age. 
Varicella, or chickenpox, is particularly a disease of infancy and 
early childhood. 

2. The short period "of invasions. 

The eruption of varicella is not, as a rule, preceded by a dis- 
tinct period of invasion ; the appearance of the rash is the first indi- 
cation of ill health that the child manifests. When an invasion period 
is present, the symptoms are of an ill-defined character, and rarely 
continue more than one day. The invasion period of variola is three 
days in duration, and is marked by characteristic symptoms. Vari- 
ola, or smallpox, is ushered in by a chill, which is quickly followed 
by high fever, vomiting, and intense headache and backache. These 
symptoms are never met with in varicella. Even a very mild case of 
varioloid presents a distinct and moderately severe period of invasion. 
Occasionally, however, it is hardly noticeable. 

3. The superficial and vesicular character of the cutaneous lesion. 
The varicella pocks are more bulb-like (and the papules do not 

have a hard, shotty feeling like those of smallpox), and also the areola- 
tion around the blebs of varicella is not so deep. When the pock of 
varicella becomes confluent, and in .some places umbilicated, the diag- 
nosis may for a time be very difficult. Acute pemphigus, varicelli- 
form syphilides, and certain other skin affections, as bulla?, occasion- 
ally closely resemble varicella, but are usually distinguished without 
difficulty by being apyretic, or by the slow development of the vesicles. 
In varicella a small vesicle quickly forms in the center of the 
papillae, remains a vesicle filled with clear or opalescent fluid for twenty- 
four or forty-eight hours, and then dries into a light, easily-detached 
crust. The variolous eruption passes through a distinct papular stage, 
lasting three or four days. The papules of smallpox are well devel- 
oped, raised markedly above the skin level, and by the diagnostic 
hard, shotty character of the base are shown to be situated deep in 
the cutis vesa. The papules become vesicular on the sixth or seventh 
day, and by the ninth day the vesicles are transformed into umbili- 
cated pustules. 



528 Varicella. 

Prognosis. — The prognosis is always favorable, and the profession 
and laity look upon it as a trifling disorder. 

Treatment. — Commonly no prophylactic treatment of varicella by 
isolation of the affected person is necessary, although enfeebled chil- 
dren should not be exposed to the disease. 

The child with varicella should be kept quietly in bed, during 
the febrile period, and the indications of the fever met as occasion 
demands. Rarely is any treatment demanded other than quiet and 
light, nutritious food, and the proper regulation of the temperature of 
the room. 

The lesions upon the face should be carefully watched, to prevent 
scars ; keep the face anointed with some bland oil, as olive-oil or coco- 
nut-oil. 

The vesicles upon the face should be punctured, and cleaned with 
a mild antiseptic lotion, such as boracic-acid solution. This will favor 
their rapid recovery. 

The continued ansemic condition resulting from an attack of 
varicella should be met with an alterative for the blood, as syrup of 
the iodide of iron, and a bitter tonic ; and in children in whom there 
is left a tendency to cutaneous eruptions, attended by glandular enlarge- 
ments, a course of cod-liver oil (Wampole's) is very serviceable in 
building up the constitution. A careful regulation of the diet is of 
much importance. 



CHAPTER XXXVIII. 
VARIOLA (SMALLPOX). 

Definition. — Variola is an acute contagious fever, characterized 
by an eruption, whose unit is at first a hard papilla, then an unibilicated 
vesicle, then a pustule, and finally a crust. In the great majority 
of cases one attack destroys the susceptibility to subsequent contagion. 

Etiology. — The cause of smallpox is a contagium, which, it is 
thought, is probably an organism. Late in the disorder secondary 
septic infection is prone to occur, so that, according to the history of 
cases, various species of staphylococcus, streptococcus, and even a 
saccharomyces, have been found in different portions of the body. 
The nature of the original virulent organism still remains doubtful. 
"Klebs has described a tetracoccus, whilst Pfieffer and Vander-Coeff 
affirm that there is a sporozoon for the transmission of the contagium, 
and contact is not necessary. The fact that the crusts, which in 
China are preserved for the purposes of inoculation, retain their 
activity for two years, shows how tenacious of life the germ is, and 
the form of fomites which suffices to retain the germ." (Wood.) 

Of the first origin of smallpox we have no knowledge. It is very 
readily conveyed through the air. According to recent opinion it may 
be communicated in this way to great distances, especially from small- 
pox hospitals. (Power.) The contagium appears to be of a very 
clinging nature ; clothing, bedding material, and such like attainted 
by the secretions or exhalations of the body retain it in an active 
condition for a long time, and, unless they are very carefully 
disinfected, they may become the means of propagating the disease 
months, or even years, afterward. ' It is liable also to be spread by 
persons so slightly affected by the disease that its true nature is over- 
looked, and they are allowed to attend to their daily business and 
to associate with others. In children also cases have occurred of so 
mild a nature that no eruption appeared ; yet they were the means 
of communicating the distinct disease to others. (Collie.) Physi- 
cians and nurses are liable to carry it to another; therefore extreme 
care should be exercised to prevent the spread of the disease in that 
manner. The contagium chiefly finds entrance into the system through 
the respiratory organs, and there is much evidence to show great resist- 
ive power in the digestive organs. The disease certainly exists in 
enormous quantities in the pustules and scabs; but it may escape 
from the body with all the excretions, and is abundantly given off 
during the stage of invasion before the appearance of the eruption. 

(529) 

34 



530 Variola. 

It is said that the contagion is most active when the pus formation 
is most abundant. It attacks all ages and both sexes. Very few 
persons, unless protected by previous attacks, are insusceptible to the 
poison, though there appear to be certain families in which there is a 
distinct hereditary immunity. In all probability the parents of such 
immunes had smallpox; hence their offspring would not be so suscep- 
tible to the disease. Certain races, notably the negroes, seem to be 
more susceptible than others; but the statement that has been made 
that other races, such as the Hindoos and Australians, are insusceptible^ 
is said to be incorrect. (Wood.) 

* Pathology and Pathological Anatomy. — Our present knowledge,, 
according to the various authors, does not warrant any definite state- 
ment as to the exact nature of the contagium, for, so far, it has baffled 
the researches of the most careful investigators. The skin presents 
the remains of an eruption, either as crusts, pustules, or ulcers, which, 
in hemorrhagic cases, are infiltrated with blood. Similar lesions to 
those found on the skin, but not so typical, are found in the mucous 
membranes, principally on those which are exposed to the air. The 
mouth, pharynx, nares, larynx, and trachea are the most frequently 
affected; but in severe cases pustules are found in the oesophagus, 
bronchi, and air passages, in the rectum near the anus, in the vulva,, 
in the vagina, and often in the urethra close to the orifice. "The 
blood in fatal cases is dark and coagulates imperfectly." "The 
dependent portions of the lungs are often collapsed, injected, and 
©edematous, and patches of lobular pneumonia or broncho-pneumonia 
are frequent. The heart is flaccid, of a pale gray color, from granu- 
lar degeneration of its muscular fibers. The liver and kidneys also 
show evidences of parenchymatous degeneration, and the spleen is 
enlarged and soft from acute hyperplasia." Minute necrotic foci 
have been found by Weigert and Bowen in the liver, spleen, lungs,, 
and lymphatic glands. "Septicaemia and pyaemia, associated with 
metastasis abscesses, are frequent causes of death in the later stages 
of the disease. Gangrene of the vulva is occasionally seen. Post- 
mortem examination reveals large and small hemorrhages into many 
of the viscera, ecchymosis under the serous membranes on the surface 
of the brain, heart, lungs, liver, and kidneys, and extravasations into 
many of the mucous membranes." (A. D. Blackader, M. D.) 

Symptomatology. — Smallpox is among the more constant of the 
eruptive diseases. We have the so-called simple smallpox (variola 
vera) ; we have malignant or hemorrhagic smallpox, and varioloid or 
mild smallpox, as modified by previous attacks. Simple smallpox 
is divided into three varieties for the purpose of study, as we see it 
so arranged in our latest text-book : The discrete, in which the pustules 
remain distinct from one another; the coherent, in which, though at 
first distinct, they finally come in contact and join at the edges; and 
the confluent, in which, almost from the beginning, they run together. 
It must be remembered that these varieties represent simply distinct 



Variola. 531 

degrees of intensity, and that they are not sharply separated from 
one another. 

The course of an ordinary smallpox is divided into four periods: 
First, that of invasion; second, that of eruption; third, that of sup- 
puration; fourth, that of desiccation and desquamation. 

Invasion. — The stage of invasion generally comes on suddenly, 
with symptoms of severe fever. The young child becomes fretful and 
restless ; the skin is hot, and may be either dry or perspiring. Vomit- 
ing sets in early, and is generally persistent; there may be constipa- 
tion, but in young children and in severe cases diarrhea generally 
prevails for at least the first four or five days. The respiration is 
hurried, drowsiness comes on, and, if old enough, the child com- 
plains of severe headache and constant pain in the loins. Frequently 
there is abdominal pain of a colicky character, which is increased by 
pressure in the epigastric region. The drowsiness may deepen into 
stupor, and convulsions or delirium set in. The first onset, in severe 
cases, may be with a convulsion, from which the child passes into a 
state of stupor, only to be broken by repeated convulsions. In older 
children the first complaint is generally of chilliness, with or without 
a distinct rigor; this is followed by fever, great prostration, vomiting, 
and continuous backache. Sometimes there is a temporary paraplegia 
of the lower limbs, with complaint of a feeling of numbness, and 
not infrequently with an incontinence of urine and feces, which passes 
off in a few days. The tongue is coated, the tip edges being of a deep 
red ; the pharynx in many cases is congested, but not to the same extent 
as it is in scarlatina. There is much variation in the degree of fever. 
The temperature in the axilla may vary from 102 degrees to 105 
degrees Fahrenheit. The pulse is full and frequent, and ranges from 
120 to 160. These symptoms last until the appearance of the rash, 
which generally takes place on the third day, though it is sometimes 
delayed until the fourth day. It is said that frequently the most 
violent symptoms at this stage in a* nervous child eventuate in a harm- 
less varioloid ; but sometimes the tender constitution of the infant may 
fail beneath the severity of the disease, and death ensue before the 
eruption can make the diagnosis certain. Sometimes the invasion symp- 
toms are so mild that they are overlooked by the mother or nurse. 
During this stage, more frequently in children than in adults (as 
stated by various authors), certain temporary or initial rashes occa- 
sionally make their appearance. They are apt to be misleading, and 
therefore require careful attention. They generally occur about the 
second day, but it may be a little earlier or later. When they are 
erythematous in character, they may generally be classed under one 
of two varieties, scarlatiniform, resembling an erysipelatous or scar- 
latinal rash, and the macular, closely resembling the eruption of/ 
measles. Either of these, it is said, may more or less cover the whole 
body. 



532 Variola. 

Stage of Eruption. — On the third day, as a rule, the true erup- 
tion of the disease makes its appearance. Coincidently with it the 
temperature begins to fall, the pulse becomes quieter, and an ameliora- 
tion of all the symptoms takes place, except in the severer forms of the 
disease, when this relief is very partial and the fall in temperature 
is very slight. The eruption in most cases may be first noticed on the 
face, and its earliest manifestation will be found on the upper lip, 
around the alse of the nose, on the forehead, and on the chin. There 
are reported cases in very young children where the eruption makes 
its first appearance sometimes about the genitals and in the fold of 
th£ groin, or about the lower part of the loin, or on the thighs. It is 
rarely seen on the back of the wrists and on the neck, and spreads con- 
secutively, in the course of the following twenty-four to forty-eight 
hours, then over the chest, back, arms, lower part of the trunk, and 
lastly on the lower extremities. Some of the papillae may almost always 
be seen on the palmar and plantar surfaces. It is most abundant on the 
face and back of the hands, next on the neck and arms, least on the 
trunk. The eruption quickly changes into distinct papillae, and these 
again into vesicles, which are usually fully formed upon the face 
by the third day of the eruption, but do not mature upon the extrem- 
ities until two or three days later. The vesicles are found in various 
sizes, always, as stated, in the discrete form larger than in the con- 
fluent variola, and very distinctly umbilicated, except upon the face. 
They are surrounded by a red areola, and on the face are usually 
opaque and purulent by the seventh or eighth day. During the stage 
of eruption the mucous membrane of the conjunctiva, mouth, pharynx, 
and larynx, vulva, and prepuce are intensely red, and have on them 
frequently an eruption, which is usually proportionate in severity to 
that upon the surface of the body. The defervescence at the begin- 
ning of the period of eruption is often abrupt, the temperature continu- 
ing low until about the seventh day. 

Suppuration. — This period usually begins from the seventh to 
the eighth day, and lasts about four days. During this stage the 
vesicles are converted into swollen pustules, accompanied often by 
great subdermal swelling, excessive irritation of the skin, and great 
pain upon movement. In severe cases violent conjunctivitis, exces- 
sive salivation, dysphagia, dyspnoea from oedema of the glottis, or 
bronchial inflammation may occur. The fever during this period is 
pronounced; headache is usually present; the sleep is restless, and 
often there is delirium. 

The fourth period, that of dessication, may be considered to com- 
mence at the eleventh day, and to last from ten to twenty days, or even 
longer. On the face, and sometimes on other portions of the body, 
the pustules break, discharging their contents, so as to make a purulent 
mask, or each pustule in mild cases may form its own distinct scab. 
The surface, as the scab falls off, is left of a reddish wine color, often 



Variola, 533 

excoriated or ulcerated ; so the cicatrices of various form and appear- 
ance remain after convalescence. 

Complications may be expected to set in at any time, even during 
a discrete smallpox; usually they are wanting. During the stage of 
invasion there is habitually an increase in the specific gravity of the 
urine, which may rise to 1,075, and is largely due to extreme elimina- 
tion of urea through extractives. Creatinin Hanthin, tyrosin indican, 
and the sulphates are augmented ; the chlorides are diminished." 
(Fitz.) 

During the stage of eruption and suppuration, however, the urea 
is found to be diminished, while the chlorides are greatly increased. 
Defervescence is often accompanied by a critical discharge of uric acid. 

Confluent Smallpox. — "In this the lesions coalesce, sometimes 
towards the end of the papular stage, but more frequently when the 
vesicles are changing to pustules. In this type the disease always 
assumes a severe character. Diarrhea has a special tendency to appear 
in children during the stage of invasion in confluent smallpox. 

"The eruptive stage is marked especially by a failure of the con- 
stitutional disturbances to subside, and by the peculiarities of the 
eruption. The whole surface of the face becomes excessively swollen. 
The eruption appears small, slightly elevated maculae, rapidly devel- 
oping into conical papillae about the size of a pin's head, or a little 
larger, pale red in color, and distinctly indurated to the touch. On 
the second day these papillae are deepened in color, larger, more ele- 
vated, and new ones have come out in the intervening spaces, so that 
they seem more numerous than on the first day, and rapidly coalesce, 
so that in the vesicular condition the eruption seems to be bullous. 
The papillae are more distinct in the lower abdomen. They are dis- 
tinct from one another, but they are always smaller and more numer- 
ous than in the true discrete variety of the disease. The fever, though 
it may abate for two or three days, never disappears, and the pulse 
remains frequent. During the period of suppuration the swelling of 
the surface becomes enormous ; the features of the face almost dis- 
appear, the eyes being closed, while the movements of the swollen 
extremities are extremely painful. If the patient survive, desicca- 
tion begins about the eleventh day, but the fever persists, and rarely 
disappears until the fourth week, by which time the face is usually 
desquamating. Death may occur at any time during the disorder; 
it may be due to adynamia, and be preceded by violent delirium and 
coma, or may be the result of asphyxia, produced by a rapid con- 
gestion, by a bronchial pneumonia, or by an oedema of the larynx. 
Frequently death will occur through septicemia; sometimes it is due 
to a sudden cardiac failure, the result of a myocarditis. 

"Hemorrhagic or Black Smallpox. — This is the most malignant 
form of the disease. The stage of invasion is usually very short, 
accompanied with very violent vomiting, anxiety, dyspnoea, horrible 
backache, and epigastric constriction, while the rash which precedes 



534 Variola. 

the eruption is more constant and severe, and has a much greater 
tendency to be purpuric than in the ordinary disease. The hemor- 
rhages usually appear about the fifth day, first as petechial spots, then 
subconjunctival ecchymoses, accompanied by violent epistaxis, hema- 
turia, and at last bloody discharges from the mouth, intestines, uterus, 
bronchial tubes, and ears. During the whole course there is great 
adynamia, with rapid, feeble pulse, heavy, malodorous breath, not rarely 
paraplegia with retention of the urine, various anaesthesias or hyper- 
sesriiesias, diphtheroid exudation, tympanites, and sometimes enlarge- 
ment of the liver and spleen. The eruption is always discrete and of 
a ^rownish or blackish color, while the vesicles fill with blood and go 
inco pustulation. The temperature is at no time very highly elevated. 
Delirium and convulsions and terminal coma are common, but some- 
times consciousness is retained almost to the end; death occurs from 
syncope or asphyxia." "In foudroyant cases the end may be reached 
before the appearance of any rash ; more frequently it occurs after the 
rash, but before the specific eruption has been well formed. In cases 
less malignant the hemorrhage may not begin until pustules are well 
developed." (Wood.) 

Prognosis. — In the unvaccinated, it is said the younger the child 
the greater the danger. Even when the attack is discrete in charac- 
ter, almost all under one year die, and a large proportion of those under 
two years. In such, even when convalescence seems to have set in, a 
sudden change may occur about the fourteenth or fifteenth day, and 
death ensue. Above the third year the simple or discrete variety gen- 
erally terminates favorably, but the confluent is very fatal in chil- 
dren of all ages. Any enfeebling disease, such as scrofula, phthisis, 
or syphilis, renders the prognosis bad. The amount of the eruption 
governs the prognosis to a great degree, as also the extent to which the 
mucous membranes are implicated. During the development of vari- 
ola, any cessation or irregularity in its course is to be dreaded. Any 
sudden fading of the eruption or unusual pallor of the skin, any failure 
to become full and swell out about the eighth day, or any sudden 
shrinking of the pox, as if by absorption of its contents, is of the grav- 
est import, and is generally followed by death, frequently within twenty- 
four hours. On the other hand, a good defervescence on the appear- 
ance of the eruption, a bright and rosy areola, with a moderate erup- 
tion filling out well about the eighth day, a fair return of the appe- 
tite, and a moderate secondary fever with no complications, are all 
of favorable import. In the hemorrhagic forms of the disease the 
prognosis is always very bad. A few cases in which hemorrhagic 
symptoms set in during the pustular stage may recover, but in general 
death is said to be certain. Laryngitis, if severe enough to cause dis- 
tinct difficulty of breathing, is mostly fatal. Complications should 
be looked for if the secondary fever runs high. Different epidemics 
vary much in their mortality. Those occurring in summer, as noted, 
are generally more dangerous than those occurring in winter (Cursch- 



Variola, 535 

inarm), and the mortality is usually less at the end of an epidemic 
than at its commencement. Varioloid is rarely fatal, and has no com- 
plications. 

Diagnosis. — It is very important that a diagnosis be made as early 
and as promptly as possible. An error either way exposes the physi- 
cian to merited blame, which, in general, the subject will not be slow 
in making known to the doctor. Where there is any suspicion, it is 
well to have definite knowledge on the following points : Are there other 
cases of smallpox in the neighborhood I If not, has the child been 
inoculated, or has it had a previous attack of smallpox? Has there 
been any possible exposure that is known of \ 

During an initial stage, it is impossible to make an absolute diag- 
nosis ; but in the absence of effectual vaccination, and with possibility 
of previous exposure, we should regard with suspicion the symptoms 
of this stage appearing without other sufficient cause. Except in cases 
of known exposure, a physician is not hardly justified in speaking 
absolutely until the characteristic eruption fully appears in the form 
of small, distinct, "shotty," papillae, seen first on the face and fore- 
head, and perhaps on the back of the wrist, and successively invading 
the neck, trunk, arms, and lower extremities, and visible on the mucous 
membrane of the mouth and fauces. Should there be any irregularity 
in the appearance, or doubt about the symptoms, the proper course 
recommended is to wait another twenty-four hours, until the papillae 
on the face become vesicular. At this time a diagnosis ought to be 
made with certainty. 

In the suddenness of invasion, smallpox may resemble pneumonia ; 
but it is to be distinguished at once by the absence of physical signs, 
and by the intensity of the backache. Owing to the character of the 
initial rashes, not rarely mistakes of diagnosis between it and scarlet 
fever or measles have been made. It is to be distinguished from scar- 
let fever by the absence of sore throat, and by careful attention to the 
minute characters and especially to the topography of the initial rash, 
which in smallpox is always limited in its distribution, is especially 
abundant on the abdomen, and rarely, if ever, appears on the face. 
The rash of measles appears later than does the initial rash, and dif- 
fers also in its distribution. Furthermore,, in both measles and scar- 
let fever the backache is never so severe as in smallpox. Although 
the differences seem so clear, yet cases do arise in which the diagnosis 
must for a time remain uncertain, requiring the physician to wait for 
the appearance of the shot-like feel of the papule on the upper fore- 
head, before sending the patient to the hospital. 

From smallpox in the vesicular stage, varioliform syphilide, which 
is often accompanied with a pronounced fever, is to be differentiated 
by the slowness of its evolution, by the absence of backache, and by 
the fact that the temperature does not fall on the appearance of the 
eruption. Chickenpox is to be distinguished from varioloid and other 
mild forms of smallpox by the oblong form and greater size of its 



536 Variola. 

bullae, by their irregular dissemination, by the absence of distinct umbil- 
ication and suppuration, and by the lack of severe constitutional dis- 
turbances, which are so characteristic of smallpox. There are, how- 
ever, said to be cases in which for a time the diagnosis between chicken- 
pox and very mild varioloid must remain in doubt. The severity and 
universality of the hemorrhages and the abundant petechias distinguish 
malignant smallpox from malignant scarlet fever, cerebro-spinal menin- 
gitis, and other similar affections. If death does not occur before the 
fourth day, the papillae, even if they are not plainly apparent in the 
deeply discolored skin, can be felt in the region of the upper fore- 
head along the edge of the hair. (Wood.) 

Treatment. — Isolation should be insisted upon from the first 
moment at which suspicion of the nature of the disease is aroused. 
The room should be very freely ventilated, or the patient may be put 
into a large tent, if it is in summer weather. Good ventilation should 
be insisted upon, so as to prevent any condensation of the poison. 
All carpets, rugs, pictures, and surplus furniture should be removed 
from the room, to afford as few resting-places for the poison as pos- 
sible, while the personal and bed linen should be changed frequently, 
and always dropped at once into corrosive sublimate solution or into 
boiling water. 

The surface of the body should be frequently bathed, with the 
free use of carbolic-acid soap and warm water, and after the bath the 
water should always have added to it sufficient corrosive sublimate (1 
to 5,000, or if carbolic acid 1 to 200) to destroy all germs. All dis- 
charges from the body should be immediately disinfected. (See 
Typhoid Fever.) 

During the whole course of the disorder, unless there is a tendency 
to subnormal temperature, the patient should be lightly covered in 
the bed. Highly nutritious and easily digested food should be admin- 
istered, such as milk, raw or soft boiled eggs, strong broths, etc. It must 
be remembered that the suppurating process is very exhausting, and the 
patient should be fed up to the full power of digestion. The use of 
baths is of the greatest importance. In the stage of invasion the hot 
bath will generally relieve the pain, while whenever the fever is high, the 
cold bath will reduce the temperature and often moderate the nervous 
disturbances. If there is delirium and subsultus, with a temperature 
of over 102.5 degrees Fahrenheit, the bath of 80 degrees Fahrenheit 
may be used every three hours, the temperature of the water being 
reduced if it is not low enough to cool the patient. Symptoms must 
be met as they arise. Opium is especially useful in the period of 
invasion, and when there is much vomiting should be given in the 
form of suppositories. It is serviceable when in the advanced stages 
there is great irritation from the suppurating skin, or when there is 
insomnia combined with delirium. 

Laxatives in most cases are required from the beginning; but if 
diarrhea should exist, as it does sometimes, opium, bismuth, salol, and 



Variola. 537 

similar remedies are employed. Chloral given in small doses along 
with opium and hyoscine is sometimes used in controlling maniacal 
outbreaks. As prostration comes on and increases, alcoholic stimu- 
lants, strychnine, and other stimulant remedies should be used. It is 
said to be doubtful whether in malignant smallpox any drugs have 
perceptible power for good; nevertheless, various stimulants may be 
freely used and an attempt may be made to check hemorrhage by the 
use of ergot, and other hemostatic remedies. (Wood.) 

Strong light should be excluded, as it is thought it increases the 
tendency to pitting on the face and hands. For children the diet 
should be digested partially, or digestants should be used, such as 
some good preparation of pepsin or pancreatin, associated with the 
food by administering it just before or immediately after the food. 
During the invasion stage, however, only the blander fluids should be 
permitted, owing to digestive disturbances; but during the eruptive 
stage feeding must be pressed, especially if the case is severe. Much 
tact and considerable coaxing may be required to induce the little 
one to attempt to swallow, but it is important that as much nourish- 
ment as possible should be taken. In general it will be best given in 
small quantities at short intervals day and night. Variola is a self- 
limited disease, and Rillet and Barthez long ago pointed out that all 
therapeutical treatment tending to disturb its normal course is harm- 
ful. It should be remembered that with our present knowledge, we 
have no specific drug that will control or modify the course of variola. 
Depressing measures of all kinds are said not to be beneficial in chil- 
dren, and should be avoided. (Blackader, M. D.) 

For vomiting, small doses of cocaine afford much relief. Should 
it fail, other gastric sedatives, such as soda, sub-carbonate of bismuth, 
citrate of magnesia, or some mild laxative may be employed. Dur- 
ing the entire period of eruption one important indication seems to 
be to relieve the irritation of the skin and mucous membrane. Hyde 
uses a solution containing one drachm of boracic acid with a drachm 
or two of glycerine to a pint of water as warm as may be comfortably 
borne. Cloths wrung out of this should be constantly applied, chang- 
ing them as they cool. During the night-time, or when the patient is 
sleeping, they should be covered with oil silk to retain the heat and 
moisture. If the eruption is very profuse over the body, and the irri- 
tation very great, a mixture of olive-oil and lime-water in equal parts 
is recommended by Dr. Welch, to be painted over the parts from 
time to time with a large camel's-hair brush. 

Dr. Tomkyns states that he has used with much success In 
the fever hospital, Manchester, England, a thin solution of common 
starch, glycerine, and tincture of iodine (glycerine, ^ss; tinct. idini, 
3ij; solution amyli, oss), to relieve the dermatitis and prevent pitting. 

Schwimmer strongly recommends the use of the following paste : 
Carbolic acid, 4 to 10 parts ; olive-oil, 40 parts ; prepared chalk, 60 parts. 
Make a soft paste to be spread on soft linen, and with this cover the 



538 Variola. 

face and arms. The linen should be changed every twelve hours. This 
diminishes the intolerable itching and fetor of the later stages; and 
to lessen the contagium the body should be sponged with some anti- 
septic solution, such as solol (1 to 10), boric acid (1 drachm to 1 pint), 
corrosive sublimate (1 to 5,000), and carbolic acid (1 to 200). The 
sensation of the patient, if old enough, ^should be the guide in regard 
to the temperature of the compresses used, and also, in a measure, 
to the strength of the solution if the subject be an adult. When tepid 
compresses or applications are preferred to cold, they should be used. 
During the stage of suppuration and desiccation, prolonged warm baths, 
in which the patient is immersed for two or three hours once in 
twenty-four hours, and by which the local inflammation is often greatly 
reduced, is said to be the Vienna plan. If the bath can not be employed 
the patient may be washed three or four times in twenty-four hours 
with a warm solution of corrosive sublimate (1 to 5,000). Compli- 
cations must be treated on general principles, avoiding anything 
approaching systematic depletion. During the stage of convalescence, 
iron tonics are used in large quantities. The muriated tincture of 
iron is preferable. Vaccination and re-vaccination is recommended by 
most authors, as being the most effective preventive measure against 
the disease. 



CHAPTER XXXIX. 
PERTUSSIS (WHOOPING-COUGH) . 

Definition. — Whooping-cough is a contagious disease, especially 
attacking children; it depends on a specific poison, and prevails epi- 
demically and sporadically. It is characterized by fever, malaise, vio- 
lent paroxysms of coughing, with spasms of the glottis and irritation 
of the respiratory tract and catarrh. 

It attacks both sexes and all ages. It may be complicated with 
other lesions, as ulceration of the frenum lingua, enlargement of the 
tracheobronchial glands, . paralysis, convulsions, jaundice, catarrhal 
pneumonia, tubercular meningitis, and other diseases of children. 

Etiology. — The exact nature of the poison is not entirely deter- 
mined. Deichler affirms that it is an amoeboid protozoon. Accord- 
ing to AfanassiefT, it is a short bacillus, pure cultures of which, when 
applied locally, cause in the lower animals respiratory catarrh. Lin- 
naeus foreshadowed modern views when he endeavored to prove that 
tnssis sicca, or dry cough, was produced by animalcule or had an 
insect origin. The insect of Linna?us is the microbe of Pasteur. Thus 
two great minds arrived at the same conclusion. 

Since M. AfanassiefT, many experiments have been made on ani- 
mals with D. Aronval's thermostat cultures, which were injected into 
the windpipe or lungs of dogs and rabbits, of course under antiseptic- 
precautions. The animals all contracted a disease similar to whooping- 
cough, often complicated with broncho-pneumonia. Several died, and 
dissection showed that the mucous membrane of the bronchi, of the 
trachea, and even of the nose, are the chief seats of the injected 
bacteria. This same bacterium was found in the lungs and respira- 
tory mucous membranes of children who died of whooping-cough. 
M. AfanassiefT considers it to be the true cause of whooping-cough, 
and names it the bacillus tussis convulsivae. We are thus a step fur- 
ther on the way; and as Schwenker 1 and Wenat 2 have confirmed M. 
AfanassiefT's obseiwations, a great lucuna has been filled up. Whoop- 
ing-cough can not persist long without leaving some impression on 
various parts of the frame. The imperfect aeration of the blood, 
the disturbances of the circulation, the very concussion produced when 
in a severe paroxysm the child is shaken from head to foot, grasp- 
ing with instinctive haste any support it can lay hold of to break the 
force of the concussion, the incessant, teasing, harassing cough, the 



'Schwenker, Lancet, Jan. 7, 1888. 
2 Wen at, Medical News, June 2, 1888. 



(539) 



540 Pertussis. 

vomiting, can not occur without altering in some way either the tex- 
ture of the mucous membrane of the throat, bronchia, or bowels, or 
the structure of the lungs, the heart, or the brain and its meninges. 

Morbid Anatomy. — As the characteristic change in pertussis, we 
find the mucous membrane in a highly injected and irritable condition. 
There is catarrhal inflammation of the respiratory mucous membranes ; 
in life the conjunctiva? are frequently seen in a state of intense con- 
gestion, and we have hemorrhage from over-distension of the blood- 
vessels caused by the violent paroxysms. The so-called cough region, 
which is supplied by the sensitive filaments of the superior laryngeal 
nerve, — the posterior wall of the interytenoid region, — seems in most 
cases observed to be the chief focus of the disease. 

Complications. — Capillary bronchitis, usually the result of expos- 
ure to cold or of an unequal temperature, is one of the most frequent 
complications in whooping-cough. Pulmonary collapse is said to be 
the result, very frequently, of bronchitis. If one or more of the tubes 
becomes choked up with mucus during expiration, some air is forced 
out by the side of the mucus, but each respiration draws the phlegm 
into a narrower part of the tube. Air is expelled, but none is taken 
in; the consequence is that the air-sacs collapse. For our knowledge 
of this condition we are indebted to Sir John Alderson, who, in 1830, 
described the anatomical character of this collapse. 

Enlargement of the tracheo-bronchial glands is very commonly met 
with in delicate and strumous children, in whom there is enlargement 
of the cervical, inguinal, and other superficial glands. 

Pneumonia is the result of cold and other causes, as inflammation 
of the pleura; but the post-mortem appearances are found to be iden- 
tical with those observed when the patient has died from pneumonia 
uncomplicated with whooping-cough. 

We know that circulation is disturbed, and the perfect aeration 
of the blood is interfered with in pertussis. As a rule, it is observed 
that whooping-cough does not leave behind it any permanent cardiac 
lesion. We may have general disturbance of the nervous system pro- 
duced by the long-continued cough and paroxysms. In infants in 
whom the process of dentition is still going on, this disturbance may 
lead to formidable convulsive seizures, especially in irritable chil- 
dren. 

Symptoms. — Authors have divided the disease into three stages. 
Physicians as a rule do not often see the disease in the first stage,, 
as mothers do not call in a physician until the characteristic parox- 
ysms have appeared, when we hear "the whooping-cough." The first 
stage comes on unsuspectedly and insidiously. The child may be 
cross, have some slight fever, malaise, and restlessness, or the fever 
may be wanting, but when present the rise of the temperature is toward 
evening. This is called the catarrhal or first stage. The period of 
incubation in whooping-cough is usually three or four days, but it may 
be as short as forty-four hours, or may extend over a week. The 



Pertussis. 541 

mother usually thinks the child has a cold. We observe catarrhal 
symptoms, which soon pass away under a little domestic treatment. 
Castor-oil is usually given by the mother, and the chest is rubbed 
with camphorated oil, or goose grease, or something of the sort, and 
the child is better in the morning. The child may be so well that it 
is allowed to go out without any extra precautions ; but on its return 
to the house the cough is worse, and it exhibits more manifest symp- 
toms. There may be some discharge from the nose, the cough is more 
urgent, and the child is more restless and uneasy, and cries as if in 
pain. This stage progresses, and there are still more pronounced 
symptoms of catarrh. With a little more extra care, the child may 
again appear better. If it is taken from a warm room to a cold 
room, or after having been warmly wrapped up the extra clothing- 
is taken off, again there is a change. The cough returns with intensity, 
occurring in repeated attacks, during the intervals of which the child 
pants for breath. The second stage is now approaching. 

The question is asked, How long does the first stage last ? Some 
authors have estimated it as averaging from eight to fourteen days 
(Burger) ; Lombard observed the length of time to be from four to 
six weeks; Wunderlich, from three to six days; West, from two to 
twenty-five days. Wood and Fitz estimate it sometimes to be shortened 
to three days or even less ; but more frequently, they state, it is pro- 
longed up to six weeks. As a rule, the younger the child, the shorter 
the catarrhal stage. 

As the second stage is reached, the coughing becomes more parox- 
ysmal, the characteristic whoop is heard, and the nature of the dis- 
ease is assured. The child will suddenly grasp for something to hold 
onto while the paroxysm of coughing lasts. The pulse becomes rapid, 
the breathing short, and then the coughing commences. The air being 
forced out in sudden jerks, the cough is explosive, rapidly repeated, 
with almost no respiration between the expulsions of breath, and with 
an increasing turgidity and cyanosis of the face, which may continue 
until the whole countenance is dark and swollen, with prominent eye- 
balls, protruding mouth, and watery eyes ; suffocation seems imminent, 
while a long-drawn whoop is given. A repetition of the pneumonia, 
.of varying length, occurs, until vomiting ensues, or till the attack 
exhausts itself. Many children are utterly exhausted by the attack, 
though others are at once able to resume their amusement. The par- 
oxysms may be so severe as to bring on convulsions, hernia, or pro- 
lapsus ani. The paroxysms are irregular in their occurrence, and 
are most frequent at night. 

How long does this second stage last ? The duration is about 
four weeks to seven or eight weeks. Children well-to-do, who are in 
good circumstances and can have good, careful nursing and all that it 
implies, suffer less than those who have poor care. After a varying 
time, the paroxysms become less, and the child reaches the third stage. 
' There is a gradual diminution in the intensity of the paroxysms, the 



542 Pertussis. 

cough loses its peculiar character, the whoop is less frequently heard 
or is absent. The bronchial catarrh often persists for a while, then 
gradually disappears, and the course of the disease is at an end. The 
duration of the third stage depends on the hygienic surroundings and 
the care of the child. A cold will cause typical paroxysms of whooping 
long after the disease has disappeared. 

Diagnosis and Prognosis. — The diagnosis is often difficult. 
Known exposure or the prevalence of the disease in the neighborhood 
is presumptive evidence. The characteristic whoop makes the diagnosis 
simple. The first or catarrhal stage is made difficult when there is 
no knowledge of the disease in the community. The prognosis must 
depend upon the condition and age of the child. History and experi- 
ence teach us that the disease is more serious than is generally thought. 
Whooping-cough is popularly supposed to be not a very serious dis- 
ease. Statistics show a high mortality among the poor and among 
badly-nourished infants. Hence mothers should use great care, which 
can be given by parents, and save much extreme suffering from expos- 
ure to cold, which seems to prolong the paroxysms. 

Complications. — The most fatal complications of whooping-cough 
are inflammations of the respiratory tract. Broncho-pneumonia is not 
uncommon, and even in the most favorable cases may run a very slow 
and dangerous course. Atelectasis is very frequent in weakly young 
children. Emphysema is often developed, but very rarely remains after 
the disease passes off. A paroxysm may end in convulsions; the con- 
vulsion may be purely functional, but it may be due to a rupture of 
a meningeal or other cerebral vessel, and be followed by hemiplegia, 
aphasia, or other evidences of focal organic brain disease. In such 
cases epilepsy, spastic paralysis, aphasia, imbecility, blindness, or sim- 
ilar loss of function, may be the result of a permanent brain degenera- 
tion. Rachitic or tubercular tendencies are much intensified by the 
whooping-cough. (Wood.) 

Treatment. — 1. Prophylaxis. — Isolation and disinfection are as 
important and powerful in suppressing the contagium of whooping-cough 
as in the case of other diseases of the class, but probably some cases are 
improved by being taken into the air. The disease is continually met 
with in public places and in street-cars and in public vehicles or con- 
veyances. The contagion may be conveyed or carried in fomites or 
clothing. We think, however, that children with pertussis should not 
be wilfully exposed to other children, thus widely spreading the disease, 
which is the means of so much suffering, when it can be so easily 
suppressed, and save the lives of many children. Children should not 
be allowed to attend school when it is known that they have been exposed 
to the disease, till after the time has elapsed to show any catarrhal 
symptoms. It is time parents woke up to the fact that this is a dan- 
gerous disease, instead of saying, "The child only has whooping-l 
cough." Yes, as statistics show, the child only has a disease which 
causes one-fourth of the annual mortality of children in London, only 



Pertussis. 543 

a disease from which thousands of children die annually; and yet 
such high infant mortality is a matter of wonder. 

There are few diseases about which there is more lamentable 
ignorance and carelessness among the public; though it is properly 
believed to be communicable, yet no precautions are taken against the 
infection. It is popularly believed that every child must have whoop- 
ing-cough, measles, and scarlet fever; and that as it must have the 
diseases, the sooner the child contracts them the better. Let mothers 
remember that whooping-cough is not necessarily a disease of childhood, 
that children are not doomed by any law of Providence to either 
measles, scarlet fever, or whooping-cough. When it is possible to do 
so, parents should protect the rest of the family from exposure by 
isolating the case in a well-ventilated, sunny room, or send the well 
ones away to the country ; or if all the children in the family are 
infected with the disease, great care should be exercised not to let the 
diseased children play with those who are not diseased. The sick 
family of children should be kept quarantined in their home, and all 
sanitary measures should be employed, as in other infectious dis- 
eases (see Typhoid Fever), thereby preventing the spread of the dis- 
ease. It would be a blessing if it were possible to isolate every case, 
keeping the patients in a comfortable, well-ventilated, and sunny hos- 
pital for a lengthened period. Thus whooping-cough might be stamped 
out. The country people are better able to stamp out the disease, 
as each family is isolated from all neighbors, and with hygienic and 
antiseptic precautions they need not infect the whole country. This 
is impracticable in the city, but in the country, parents can keep their 
little ones (and big ones, too) at home until the disease has run its 
course in their neighbor's family, and then insist on the neighbor who 
has had the contagion cleaning up his premises ; and where this is 
impossible on account of lack of help, let all the neighbors assist the 
afflicted family in disinfecting the infected premises, and by so doing 
they will save the lives of their children. Remember that these good 
neighbors must not return to their homes afterward until they them- 
selves have been disinfected, so that they will not carry the disease in 
their clothing to their children. 

Hence the preventive measure necessary to check the spread of this 
special contagium is isolation or quarantine. Pertussis never arises 
spontaneously; spreading, then, by contagion, as it is said, some form 
of quarantine should be established to keep the healthy from the 
unhealthy. 

We realize that the children with the special contagium need the 
open air and sunshine, well-ventilated apartments, without undue 
exposure to draughts. Tightly-closed rooms aggravate the disease. In 
summer-time the child is best off out-of-doors, in the sun, unless the 
weather is very hot. A hammock in some shady place for the child 
to lie in is very useful when it is too much exhausted to resume its 
amusement after a paroxysm of coughing; in the winter-time, outdoor 



544 Pertussis. 

exercise should be confined to dry, still days, on which the temperature 
is not too low. Winds are known to be more dangerous than damp. 
In many cases, however, the child is better confined in a large, well- 
ventilated, and sunny room. The food should be very nutritious and 
palatable; for the whole tendency of the disease is toward exhaustion. 
Vomiting so often takes place that it is difficult to nourish the child, 
so that frequent feeding should be resorted to. I have observed that 
the infant takes its food best immediately or very soon after vomit- 
ing. We have noticed that warm food provokes coughing and vomiting ; 
but very soon after the vomiting, the child will resume eating, and 
may perhaps have another paroxysm of coughing. Let the child rest 
a few minutes, and in all probability it will finish its meal in comfort. 

It is essential that at night the child should wear warm under- 
clothing, at least on the body and arms, in addition to the night wrap- 
per. The temperature should be taken three times a day. Any increase 
of fever shows some complication setting in, it being most usually some 
indication of developing pulmonic catarrh. In advanced cases, it is 
said that the greatest benefit is derived from a change from the coun- 
try to the seaside and vice versa. Mild cases may progress satisfac- 
torily without medication ; but usually not only are there demands 
of patients for medicine, but the frequency of the paroxysms and 
the catarrhal irritation of the mucous membrane may be benefited by 
the administration of an emulsion of asafoetida, and a sufficient amount 
of tincture of belladonna to cause a slight dryness of the mouth or 
dilatation of the pupil is needed in order to get the full effect. The 
belladonna may also be given by atomization, so as to have its local 
benumbing effect upon the larynx. Antipyrine and phenacetine are 
very valuable drugs; they should be given in small doses for checking 
the frequency and severity of the paroxysms. They are usually well 
borne, especially phenacetine, and doses may be given, graduated 
according to the age of the patient, every four or six hours, according 
to the severity of the paroxysms. 

Some authors recommend ammonium bromide; it may be given 
frequently with great advantage. Chloral hydrate is a useful remedy ; 
it may be administered with the bromide of ammonium, at bedtime 
to promote sleep, and is very useful to prevent convulsions ; it may 
also be combined with a little opium when opium is needed to quiet the 
severe and teasing cough. 

If there is much coryza, the nostrils should be kept clear by wash- 
ing or spraying the nasal cavity or nostrils with warm salt water, or 
with the official peroxide of hydrogen diluted with ten times its bulk 
of warm and slightly saline water, or a little steam, from an atomizer, 
or from a kettle boiling in an adjoining room or in the room ; a lit- 
tle carbolic acid or thymol may be added to the boiling water. Keep 
the air moist in the room. For steam atomizer the following solu- 
tion may be used : — 



Pertussis. 545 

1>: Acid carbolic 3ss 

Potass chlorate, 

Potass bromide, aa 3ii 

Glycerine 3ii 

Aquas 3vi 

Mix. 

Keep the steaming atomizer near the child. 

Treatment must be directed to meeting symptoms, with great care 
to prevent complications. Fresh air and tonics, good nourishing food, 
the proper protection of the body, are all required. Great attention 
should be paid to the diet of a child with whooping-cough. The food 
should be such as can be easily digested, and it should be given often, 
in small quantities. Milk, eggs, soups, and puddings are epecially indi- 
cated. Keep the child built up all that it is possible with tonics and 
food to prevent exhaustion. 

To keep the bronchial tubes free from the accumulation of mucus, 
wine of ipecac, with the syrup of squills and carbonate of potassium, 
may be prescribed as follows for a child from one to three years of 
age:— 

Yy. Potassium carbonatis 3jss 

Vinum ipecacuanhas 3iij 

Syrup scillas 3j 

Syrup prunus virg ad §vi 

M. et sig. 

Give from twenty to forty drops to a child from one to three 
years of age, only when needed to aid the child in freeing the bronchial 
tubes of mucus. 



35 



CHAPTEE XL. 
PAKOTITIS (MUMPS). 

Definition. — Parotitis is a contagious epidemic, consisting of an 
inflammation and enlargement of the parotid glands. It generally 
occurs in youth, is acute in origin, and accompanied by fever; it is 
followed in some cases by abscess of the gland, but usually subsides 
within a week or ten days without leaving any trace. 

A condition of tumefaction and inflammation may be set up in the 
parotid gland by a blow or some external injury, and following such 
trauma an epidemic parotitis may arise. 

Etiology. — There is nothing known of the essential nature of the 
origin of the disease. Mumps especially prevails in the spring and 
autumn, and it is thought that the disease is not intensely contagious^ 
as we have often seen children exposed who never took it. The law 
of spreading the disease is not clear. Infants are seldom attacked^ 
and the affection is confined to the period of childhood and early 
youth, although sometimes adults who have not previously had it are 
affected. Males are more prone to be affected than females. One 
attack gives immunity from another where both sides are affected. 

Symptoms. — The period of incubation is variously given from 
six days to two weeks. The prodromic symptoms usually appear 
about a week after the exposure. The first symptoms are swelling 
and pain just below the ear on one side, and a feeling of languor and 
malaise, loss of appetite, irritability, slight fever or feverishness. The 
swelling increases rapidly and extends forward, backward, and down- 
ward till the side of the face and neck are implicated. The swelling 
is first upon one side, and is usually followed by swelling on the oppo- 
site side within one or two days. There is pain on an attempt to open 
the mouth ; the head is at first held towards the affected side to avoid 
tension of the affected muscles and tissues, but when the affection is 
bilateral the head is held rigidly erect. Swallowing and even speech 
become very difficult. In favorable cases the symptoms subside in 
seven to ten days, with a rapid convalescence. 

A frequent and curious complication is an orchitis or swelling of 
the testicle (usually on the same side), with scrotal oedema, while in 
girls the ovary, vulva, or mammas are similarly affected. This inflam- 
mation is not generally severe, and runs about the same course as 
regards time, as the parotitis. The left testicle is said to be most 
frequently attacked. 
(546) 



Parotitis. 547 

Diagnosis. — The diagnosis of mumps consists in distinguishing- 
bet ween a parotid and a lymphatic swelling. The history of the 
exposure or an epidemic, with the appearance of the tumor and its 
local manifestation, make the case so plain that it can hardly be mis- 
taken for an enlarged cervical gland. The best test is said to be a 
point of intense tenderness high up in the angle of the jaw immediately 
behind the ear. 

Prognosis. — The prognosis is favorable, no cases reported of 
death being due to mumps. The duration of the disease is about ten 
days. 

Treatment. — The disease being self limited, not dangerous, of 
short duration, and its specific cause unknown, a laxative, confinement 
in bed or to a warm room, and a light, liquid diet are usually about all 
that is necessary. Local applications are generally used for comfort, 
and also cold compresses, or ice poultices; an ice bag applied may be 
more agreeable. 

Some authors recommend rubbing the gland with belladonna- 
mercurial ointment (equal parts) ; this is efficacious Avhen resolution 
is slow. In typhoid cases appropriate support and stimulants should 
be given. If orchitis occurs, absolute rest in bed should be enforced, 
the scrotum well supported, and the belladonna-mercurial ointment 
used. When the tenderness has subsided, strapping should be employed. 

If irregularities of the digestive system exist, they should be cor- 
rected according to the judgment of the physician. Saline laxatives 
will control the tendency to constipation. Should there be great rest- 
lessness or marked cerebral symptoms, it will be well to apply cold to 
the head, and give small doses of antifebrine, from one and a half to 
two and a half grains, according to the age of the child, every four 
hours, till headache is relieved. Small doses of aconite act well in 
some cases. Some authors recommend chloral hydrate or morphine 
in extreme cases. If a tendency to suppuration is noticed, shown by a- 
tenderness and redness of the skin, a leech or two may be applied 
behind the ear. The galvanic current of electricity should be used, 
the positive pole applied over the tumor, the negative pole over the 
spine between the shoulder or just below the nuche of the neck. Give 
from thirty to forty milliamperes for half an hour. It has a very 
soothing effect on the nervous system, and prevents suppuration. The 
galvanic current may be applied twice a day in severe cases. Should 
an abscess become inevitable, its formation should be hastened by 
poultices made of flaxseed meal ; and when formed, it should be opened, 
and its contents thoroughly evacuated, to prevent complete disorganiza- 
tion of the gland, or a possible perforation of the cavity of the tym- 
panum. 



CHAPTER XLI. 
ERYSIPELAS. 

Definition. — Erysipelas may be defined to be a dermatitis having 
a tendency to spread rapidly, accompanied by comparatively severe con- 
stitutional symptoms, with rapid resolution and complete return to the 
normal condition. It is also contagious under special conditions, as in 
case of wounds. 

Etiology. — Anybody and everybody is liable to be affected with 
erysipelas. We find erysipelas occurring with greater or less fre- 
quency in all places, at all seasons, and under most varying external 
conditions. It may follow injuries or operations, as is often seen, 
when it is called surgical or traumatic erysipelas. Erysipelas may 
arise without any injury, as the medical or idiopathic form. 

The contagion of erysipelas consists of the streptococcus originally 
described by Fehleisen under the name of streptococcus erysipelas, bur 
now is generally believed to be identical with s. pyogenes. Hippocrates 
spoke of this disease in his writings; it is also referred to by Galen, 
who supposed that a bilious humor, in its efforts to escape from the 
blood through the skin, caused erysipelas. 

This organism has been repeatedly found in phlegmonous sup- 
puration, in ulcerative endocarditis, and in puerperal endometritis. 
The organism occurs in chains. It is thought that in medical ery- 
sipelas the organism finds its way through some crack, excoriation, or 
abrasion in which it effects a lodgment, and that all erysipelas is the 
result of inoculation at the beginning of an outbreak. 

The causes are the direct and the predisposing. The disease is 
rare before puberty, and still less frequent in the very old. Certain 
individuals and certain families are more susceptible to the poison than 
others ; excessive or chronic alcoholism, Bright's disease, and lowered 
vitality are predisposing causes. Recently-delivered women are espe- 
cially prone to the disease. The contagion is not usually very virulent, 
but it can be conveyed by a third person, and may lurk in furniture or 
on the walls or fomites, etc. Under special circumstances not under- 
stood, the poison of erysipelas becomes endowed with great virulence 
and reproductive power, resulting in epidemics. It is said to be more 
frequent in the first year of life, and after that age it occurs as often 
in adults as in children. 

Seasons. — Erysipelas is supposed to occur more frequently dur- 
ing the cold than during the warmer months. This is not invariably 
the case, as it does occur during the summer months ; for we see it 
(548) 



Erysipelas. 549 

reported that in Paris, in 1861, one of the severest epidemics occurred 
in the summer-time. Not infrequently erysipelas returns in the same 
patient every year or oftener. This is especially the case when the 
face is the seat of the disease, and in instances where chronic rhinitis, 
eczema, or some other form of chronic inflammation exists, from which 
infection occurs. 

Symptoms. — The incubation stage is variable, or from three to 
seven days. In children over six months of age a rash is seen that 
resembles that of erysipelas in adults, differing only in slight respects. 

Erysipelas may be introduced by a prodromal stage. The child 
may be drowsy or restless, with more or less fever. With adults who 
complain of headache and malaise, it is usually ushered in by a chill, 
which is sometimes very severe, followed by a rapid rise of temperature. 

In younger children there are often convulsions and vomiting 
following the chill. The temperature may rise as high as 105° Fahren- 
heit. Usually the dermatitis begins to develop immediately. There 
is a feeling of heat, tension, and pain in the affected part, which 
becomes mottled pink and somewhat oedematous. The patches grad- 
ually become more intensely red, and coalesce to form a single fiery 
patch, and the color disappears on pressure and reappears when 
pressure is removed. The erysipelas is slightly elevated, and is often 
separated from the sound tissues by a sharp ridge, which can be felt 
if not seen. The surface is smooth and shining, and often becomes 
vesicular or even pustular within twenty-four to forty-eight hours. 
From this elevated edge the erysipelatous infiltration rapidly extends 
to the neighboring skin ; and as the disease progresses, the parts behind 
gradually become paler, and within two or three days have all the 
appearances of healthy skin. The disease may extend more or less 
rapidly, and over a smaller or larger territory. The fever remains 
high through the progress of the disease, and is accompanied by more 
or less constitutional symptoms. The appetite is lost. Nausea, 
vomiting, intense headache, and thirst are present. The tongue is 
covered with a thick, dry coat. The urine is passed in small quanti- 
ties, and frequently contains albumin. Sleep is much disturbed. In 
some cases there may be delirium. The mucous membrane adjoining 
the skin is oftentimes likewise involved in the process. In the cases 
terminating in recovery, the redness gradually becomes pale, the swell- 
ing subsides, and the fever disappears. "Where death ensues, it usu- 
ally occurs while the temperature is high. 

The Seat of Commencement. — Erysipelas begins most frequently 
about the face. There is some local affection of the skin as its point 
of origin. This is most frequently situated where the skin passes into 
the mucous membrane, at the nose, near the angles of the eye, about 
the nostrils, ear, or chin. The genitals may be its seat of origin. The 
writer witnessed a case of erysipelas in an infant six weeks old who 
was affected with the disease of the vulva. It was thought to be due 
to the diapers being washed with two strong soap and not well rinsed, 



550 Erysipelas. 

which caused an inflammation ; erysipelas took place, and resulted in 
death. (Mothers should take warning and never use any soap but 
c as die for washing the infant's napkins, and should rinse them 
thoroughly.) Erysipelas may arise (as reported by O. P. Eex, M. D.) 
in the mucous membrane, as, for example, in the pharynx, and may 
then extend outward to the skin and then run its usual course. 

In fact, many of the cases of facial erysipelas in which no point 
of origin can be found, and which were formerly thought to be idio- 
pathic, proceed from the interior of the nose. These internal forms 
may pass outward upon one of the following routes : First, to the lip ; 
second, through the choanse and nostrils ; third, through the nasal cav- 
ity and lachrymal ducts ; fourth, through the Eustachian tube, passing 
through the middle ear to the external ear. The tympanum offers no 
obstruction. Many of the cases of erysipelas which appear at the root 
of the nose pass through the lachrymal duct from the interior of the 
nose. Under such circumstances the lachrymal sac appears distended, 
as when obstruction of the duct occurs. This sign may precede the 
external erysipelas, which occurs with greatest frequency in the head, 
next on the trunk and extremities. Upon the surface of the skin ery- 
sipelas usually begins as a mottled pink patch, which rapidly becomes 
dark and confluent. It runs in the direction of the lines of least ten- 
sion of the tissue. At parts where the subcutaneous tissue is firm and 
adherent, the progress of the disease is arrested, as, for example, at 
the base of the skull, over Poupart's ligament, etc. (Rex.) The 
surface of the skin may be smooth and glistening, but is often covered 
with vesicles that vary in size. The blebs are sometimes tinged with 
blood, and gradually become turbid from admixture of pus and epi- 
thelial cells with the serum. There is always more or less swelling 
and redness, depending upon the severity of the disease. On the third 
to the fifth day the erysipelas subsides, and the affected parts gradually 
facie. The vesicles are absorbed, or burst, or dry to yellowish crusts. 
In the subsequent desquamation the cuticle is shed in a fine scurf, or 
peels off in layers. 

In the new-born, erysipelas usually begins about the navel or in 
the region of the genitals. On the first day all that is seen is a slight 
blush of the affected parts. The infant suckles well, and may not have 
any fever. This may continue for three or four days, especially if 
the child is robust. Soon, however, a change occurs. High fever 
develops; the child refuses to nurse, or takes the breast reluctantly; 
and it nurses irregularly, and vomits that which it has taken. The 
infant becomes restless, sleepless, and cries continuously; the pulse is 
irregular, small, and frequent. Diarrhea with stools that are yellow 
occurs in the beginning, but later the dejecta, or stool, becomes green 
and liquid. At the same time the affected skin becomes enormously 
distended and glistening. The tension of the part is so great that it is 
difficult to make an impression, and this when made rapidly dis- 
appears. Phlegmonous inflammation with the development of sub- 



Erysipelas. 551 

cutaneous abscesses is very frequent. In many cases gangrene of the 
affected parts is said to occur. Death almost invariably results. The 
child either becomes more and more soporous, and finally passes away 
in a condition of coma, or death may be ushered in by convulsions. 
The course of erysipelas in a new-born is more erratic than in adults, 
but the progress of the disease is not attended with the same exacer- 
bations of fever; the fever does not usually reach the height which it 
attains in older children. The disease generally lasts from five to 
fifteen days; but the progress of convalescence is often retarded by 
abscesses or gangrene. Death may be hastened by complications, which 
readily ensue, especially peritonitis, which is apt to be produced by 
extension of the inflammatory process through the umbilical vein. 
Meningitis, pleuritis, and pulmonary complications are by no means 
rare. 

Course. — Erysipelas is an acute disease, and runs its course, as a 
rule, in from ten to fourteen days. The duration is longest where the 
trunk is involved, and shortest where it is localized on the extremities. 
Relapses of erysipelas are frequent. The second attack usually has 
the same seat and runs the same length of time as the first, but is apt 
to be lighter. 

Gastritis and enteritis may exist as primitive diseases, but as such 
are rare. 

In puerperal women with facial erysipelas rigorous antiseptic 
precautions will almost invariably prevent local infection of the gen- 
itals. The vulva should be kept well covered with antiseptic dressing. 
Complications. — In adults and children suffering from erysipelas, 
meningitis, neuritis, pleuritis, arthritis, pericarditis, myocarditis, and 
endarteritis have been reported and proven to occur ; but these dis- 
eases are less frequent than endocarditis. Albuminuria is commonly 
present in ordinary erysipelas, and also of all visceral complications 
nephritis is the most common. 

Diagnosis. — The symptoms have been discussed, and the diagnosis 
of external erysipelas requires no discussion. The history of exposure 
to the infection is difficult and often impossible. The rapid spread- 
ing of the disease, with the acute inflammation, swelling, and the serous 
character of the bleb, the exudate, the chill and fever, and depression 
are characteristic signs of the disease. 

Prognosis. — In older children, erysipelas, as a rule, runs a favor- 
able course. However, while this is true, we do have epidemics in 
which the prognosis is much less favorable. Erysipelas of the new- 
born is a very malignant disease. We see statements of nearly all 
observers that in the case of almost all infants under three weeks who 
become affected with erysipelas, the disease results fatally. After the 
second year the child is not in any more danger than an adult. The 
feebler the constitution, the greater the danger. 

In adults migraine is considered a grave form, and is apt to be 
prolonged. In puerperal cases, or in pregnant cases, the prognosis is 



552 . Erysipelas. 

said to be good so long as inoculation of the genito-urinary tract is 
prevented. 

Treatment. — In prophylaxis, or measures for the prevention of 
the spread of the disease, isolation is absolutely necessary, as the con- 
tagious character of the disease has been established beyond a possible 
doubt. The experience in all hospitals in which erysipelas has pre- 
vailed, proves the necessity of isolation or quarantine of affected cases. 
In the new-born scrupulous cleanliness with antiseptic treatment of the 
umbilical cord, especially where the mother is the victim of puerperal 
disease, may, in many cases, save the life of the patient. In the treat- 
ment of erysipelas we have innumerable remedies that have been pre- 
scribed with favorable results. 

In private houses we do not consider that strict isolation is essen- 
tial. It would be as well, however, to keep the children in some dis- 
tant part of the house, and use great care in keeping up the asepsis. 
The sick-room, bedding, furniture, and draperies should be kept clean ; 
it is better to remove all unnecessary furniture from the room. Do 
not allow any accumulation of rags or dressing that has been used 
about the patient to remain in the room. These must be burned up 
as soon as possible after using them. 

The skin should be washed with corrosive-sublimate solution (1 to 
1,000), then thickly anointed with an equal part of ichthyole and 
vaseline, and covered with a thin layer of antiseptic cotton or gauze. 
The oxide of zinc ointment, made with vaseline, gives relief and sub- 
dues inflammation; if there is much burning, it may be used instead 
of the ichthyole dressing, — oxide zinc two drams to one and a half 
ounces of vaseline. The face should be washed with the corrosive- 
sublimate solution, as above advised, two or three times in twenty-four 
hours, keeping the affected parts covered with the ointment, putting it 
on frequently. For internal treatment I have found the tincture per- 
chloride of iron given every four hours both day and night, according 
to the severity of the disease, to be good. For an adult the dose is 
from ten to twenty drops in a large wine-glass or tumblerful of water, 
to be taken through a glass tube or quill, to prevent the enamel of the 
teeth from being affected. The mouth may also be washed out with a 
little baking soda and warm water after each dose has been taken. 
Quinine and strychnine may be administered according to the age in 
proportion to each individual case. Constipation, diarrhea, restless- 
ness, insomnia, and other symptoms should be met as they arise. 

Of all the antiseptics for infants, turpentine is said to be the best. 
A two per cent solution, used as a spray every two or three hours, 
is highly recommended by Verneuil, Hueter, Tillmann, and Fehleisen. 

Formerly turpentine was highly esteemed as an external applica- 
tion. Lueche, who finds a fall of temperature and a diminution of 
burning after each application, believes that the erysipelas passes off 
more rapidly. 




Erysipelas. 553 

Kacyorowski advises a mixture of carbolic acid one part with tur- 
pentine ten parts. After each, lead-water compresses are used, and in 
severe cases ice poultices are used. Under this treatment it is said 
that the skin turns intensely red, but the erysipelas is aborted in from 
twenty-four to forty-eight hours. The writer would recommend equal 
parts of sterilized linseed oil with the turpentine, with a very little 
carbolic acid added to it, for gangrenous cases. 

Ichthyol two parts, glycerine one part, and ether one part, applied 
externally, is said to be very efficacious for infants. Rice flour, talcum, 
bismuth, etc., are used for cooling the surface. 

The writer has found the carbolic-acid lotion, 1 to 500 parts of 
warm sterilized water, a useful remedy; wash thoroughly, keeping the 
parts anointed. Or good results may be obtained from the use of 
corrosive-sublimate solution, 1 to 5,000 parts of sterilized water, and 
followed by the ichthyole and vaseline ointment, with, as internal 
treatment, from three to five drops of perchloride of iron every three 
hours for a child under five years of age, also small doses of quinine 
three times a day, with good, nutritious food at short intervals, and 
every antiseptic precaution. 

Good, faithful nursing, both day and night, and keeping the tem- 
perature of the room at about 68° or 70° Fahrenheit, is a very neces- 
sary aid in producing favorable results. 

In some cases good whisky should be employed; it may be added 
to the milk or used in an egg-nog, or it may be administered in pep- 
tonized milk. 

Benzoate of soda, large doses, is highly recommended by Haber- 
korn, who claims that it reduces the temperature to normal in twenty- 
four hours; also large closes of quinine are recommended for the 
reduction of temperature, !No depressing remedies should be used. 

In phlegmonous erysipelas the pus should be evacuated early and 
thoroughly, and the parts should be washed thoroughly with corrosive- 
sublimate solution and the ichthyole and vaseline equal parts applied 
and antiseptic gauze over this till the disease is under control. Then 
oxide of zinc ointment may be used till well. The child may have to 
be nourished by rectal alimentation in cases where there is obstinate 
vomiting. Strict attention should be paid to nursing and dietary. 

In adult cases, the tincture of perchloride of iron may be given 
in 20 to 30-drop doses, in a half tumbler of water taken through a 
tube every four or six hours till fever abates; give quinine from two 
to three grains every three or four hours till well. Keep the liver 
active by giving small doses of calomel, followed with Epsom salts as 
necessary ; use the above-prescribed lotions and ointments ; keep the 
affected parts covered with antiseptic gauze. 



CHAPTER XLII. 

» 

RHEUMATISM. 

Definition. — Rheumatism is believed by many authorities to be of 
infectious origin. It is an acute febrile disease, characterized by 
inflammation of various joints in succession, profuse sweating, and a 
tendency to endocardial inflammation. 

The term rheumatism has been used very extensively to indi- 
cate almost any affection accompanied by pain and tenderness of joints 
and muscles, and to include morbid conditions of widely different 
natures. 

Etiology. — The immediate cause of rheumatism is chilling of 
the surface of the body. Exposure to cold is most effective when 
the body has been previously heated by exercise or by sitting in a 
hot room, and the skin is perspiring and its vessels relaxed. Under 
these circumstances, a draught of cold air or damp clothing from 
sweating is a frequent exciting cause of rheumatism; but it may be 
induced without overheating by prolonged exposure to any cooling 
influence, as a damp bed, or wet clothes, or an east wind. In the 
case of children these sources of chill are especially frequent; a 
child will perspire freely while romping and playing games, etc., and 
then stand about, indifferent, of course, to the dangers of wet feet 
and currents of cold air. It occurs most frequently in the colder 
months, least often during the summer. Both sexes are alike affected, 
especially during early adult life; but it is rare in infancy and old 
age. It prevails in certain families and especially in families that 
have a gouty inheritance. The young are strongly predisposed to 
attacks of acute rheumatism, while later in life muscular rheumatism, 
and still later in life unmistakable gout, become manifest. Some 
authors say that members of gouty families are not specially prone 
to acute rheumatism, nor are families showing a strong hereditary 
predisposition to rheumatism particularly liable to the manifesta- 
tions of gout. 

It is stated that the endocarditis of rheumatic fever is acute and 
usually associated with the presence of bacteria, while that of gout 
is chronic, without bacteria, and with degenerative aortic changes. 
We especially find rheumatism among persons whose occupation exposes 
them to sudden draughts of air and extreme changes of temperature 
when in a profuse perspiration, which is quickly checked by these 
exposures. 

In children it is believed that erythema, tonsillitis, chorea, pleurisy, 
(554) 



Rheumatism. bbb 

and tendinous nodules may have a rheumatic origin as certainly as 
articular inflammation or pericarditis. They are found associated 
with articular rheumatism, and when alone are met with especially 
in rheumatic subjects. We should regard all these affections in cer- 
tain instances as manifestations of the rheumatic state, although they 
may be set up in other instances by other causes, just as arthritis or 
pericarditis, while usually rheumatic, may be due to scarlatina, sep- 
tic poisoning, or pyemia. They are said not to be invariably but 
most commonly rheumatic. Any one of the phases may be absent, 
one only may be present, or two or three, or the whole series may 
be complete in the same patient. For example, there may be artic- 
ular affection alone, or there may be in addition pericarditis or endo- 
carditis, or these may occur without any affection of the joints, 
or with chorea and tendinous nodules, or there may be erythema 
or tonsillitis instead of any of these or in addition to them. This 
is constantly seen in clinical experiences. 

The theory of the infectious origin of rheumatism is most popu- 
lar at the present time. It is based on the resemblance and similarity 
of distribution of many of the lesions to those found in septicemia 
and pyemia, the frequency of relapses, and the occasional occurrence 
of athritis in such infectious diseases as scarlet fever and dysentery. 
Additional support of the theory is derived from the occurrence of 
apparent epidemics at certain seasons in limited localities, especially 
in households, and the discovery of bacteria in the fluids from the 
joints and from inflamed endocardium and pericardium. 

The observations made by Sahli suggest "that the various local 
lesions of acute rheumatism may result from a multiple localization 
of bacteria. No specific bacterium has as yet been found, but it is 
possible that various bacteria may be concerned, and that other fac- 
tors may be necessary." 

Pathology. — The exact method in which the child acts in pro- 
ducing rheumatism is extremely 'obscure. Several hypotheses more 
or less plausible have been propounded. Of these, one of the most 
favored is that it is due to the accumulation of lactic acid in the 
blood, as originally suggested by Dr. Prout and supported by Todd. 

The author has inherited a rheumatic and arthritic diathesis, 
and can speak from experience, that lactic acid will provoke an attack 
of rheumatism and swelling of the joints in forty-eight hours or less 
time, also that milk diet will produce a similar condition. 

The author has had patients who inherited rheumatic dia- 
thesis, and the milk diet had to be discontinued, because they improved 
more rapidly without the use of milk. 

Symptoms. — The different forms of rheumatism, the nature and 
severity of the symptoms between acute, subacute, and chronic articu- 
lar rheumatism, will be noticed separately. 



556 Rheumatism. 

ACUTE ARTICULAR RHEUMATISM. 

In adults this disease is of rapid onset, sometimes appearing 
within a day or two after the sudden exposure of a heated person 
to cold. There is a chilly sensation, followed by fever, morning 
remissions, and evening exacerbations; the temperature may reach 
104° Fahrenheit. Tonsillitis may at times be present, and may pre- 
cede or accompany the attack. 

The joints become red, swollen, and painful. They are often 
symmetrically affected, and recurrences are frequent. The articulations 
of the lower extremities are usually first to become inflamed; then 
thie upper extremities, occasionally the hip, jaw, vertebras, and pelvic 
symphyses. The swelling is due to the exudation of the synovial cav- 
ity, which may cause fluctuation, but it is partly dependent upon 
oedema of the surrounding tissues. The pain is more severe on mov- 
ing the joint, and is usually worse at the outset of the inflammation, 
and diminishes as the exudation increases. It may be limited to the 
joint, or may extend along the course of the neighboring tendons or 
nerves. One or more joints may be affected at the same time. In 
the milder cases the affected joints are free from the inflammatory 
disturbances in the course of a few days. In severe cases the arthritis 
may be persistent for several days. Profuse sweating with a sour 
odor accompanies the inflammation of the joints, and increases as new 
joints are attacked. The perspiration is said not to contain lactic 
acid. The respiration is accelerated, the pulse quickened; headache, 
loss of appetite, and nausea accompany the fever. The temperature 
at first shows but little variation, and exacerbations of fever take 
place as other joints are attacked, and remissions of temperature occur 
as the inflammation subsides. A continued high temperature remains 
for some time after the swelling of the joints abates. The urine is 
scanty, and high-colored ; its specific gravity is from 1,025 to 1,090 or 
more, and there are uric acid and urates. Uric acid at times may be 
increased or diminished. Urea is often diminished. As the fever 
subsides, the urine increases in abundance and becomes paler. 

In determining a case of rheumatism in children, a study of the 
disease leads to a broader conception of its nature, and compels the 
inclusion within its scope of many morbid affections in addition to 
the arthritic. While this is the worst feature of the complaint in 
adults, in childhood it is often entirely absent in an attack which is 
undoubtedly essentially one of acute rheumatism. Moreover, many 
of the phases of rheumatism which, viewed from an adult standpoint, 
we are accustomed to regard as complications of a central- joint affec- 
tion, appear in childhood as initial or chief phenomena. 

Arthritis is at its minimum, endocarditis at its maximum. Endo- 
carditis or perocarditis may appear first, or pleurisy, or chorea, or 
tonsillitis, or nodules, or an erythema, or an arthritis, and these may 
be grouped in any child. As Dr. Barlow has well remarked, the 



Rheumatism. 557 

tendency is to isolation and separation of the phenomena. "These 
draw more closely together as time passes on; the disease tends to 
appear as a whole instead of in disjointed parts; some features become 
accentuated, as the joint affection; others grow less constant and con- 
spicuous with advancing age, as the tendinous nodules and chorea, 
and these finally disappear — except in rare instances — with the 
advent of adult life.' 7 

In cases of arthritis — in some instances — a little tenderness and 
swelling of knees or ankles or wrists may remain, possibly limited 
to a single joint, or even less than this, only a mere stiffness and 
tenderness on movement, or even a slight feverish attack, recognized 
afterwards as rheumatic in the light of developing heart-disease. 

The following case illustrates this form: "A girl three years of 
age was feverish with no signs of any special ailment. Two days 
later the great toe of one foot became red, swollen, and tender ; no 
other joints were affected, and it was supposed at first to be merely chil- 
blains. Two days later still, both ankles were tender and very slightly 
swollen. The temperature was found to be 102 degrees Fahrenheit. 
The condition was now judged to be rheumatic, and the heart was 
examined. A full-blowing mitral murmur was found to exist, which 
persisted for many weeks. The jpint affection quickly disappeared 
with rest and salicine treatment, and after many weeks the mitral 
murmur finally disappeared." (Cheadle, M. D.) In many cases the 
rheumatic inflammation is limited to tendons or their sheaths, as in stiff 
neck, which is occasionally the only manifestation of genuine rheuma- 
tism. 

One of the most misleading signs of rheumatic joint, or tendon 
affection, is when it is limited to stiffening of the hamstring tendons 
at the back of the knee. The following case illustrates this form of 
rheumatic arthritis. A little girl four years old had difficulty in 
putting down the heel of the right foot. The case was looked upon 
as a surgical one of incipient talipes varus, and the limb was steadily 
galvanized. ~No improvement followed, and the patient was treated 
medically. There was no deformity; but the disinclination to walk 
was extreme. The foot could be put to the ground, but the knee was 
kept bent. Upon examination both knees were found to be tender, 
especially at the back in the hamstring tendons, and they were slightly 
swollen. The temperature was 100 degrees Fahrenheit. It was fur- 
ther ascertained that the child had suffered from pain and stiffness of 
both knees and ankles from time to time for the past six months. 
There was no cardiac or other sign of rheumatism; but the mother 
had had rheumatic fever, and the condition was judged to be a rheu- 
matic arthritis. Under salicine treatment and citrate of potash the 
stiffness and retraction of the heel, which had lasted for weeks previ- 
ously, entirely disappeared in a day or two, and the child walked per- 
fectly 7 . 



558 Rheumatism. 



COMPLICATIONS. 



Heart Disease, Endocarditis. — In the rheumatism of childhood 
heart-disease plays the most prominent part. Endocarditis appears with 
the joint affection in the majority of cases, and a small proportion of 
children only escape it; if arthritis, then almost certainly endocar- 
ditis. 1 But oftener it is accompanied by the eruption of subcuta- 
neous nodules, so intimately associated with evolution of valvulitis of the 
heart in early life, or by chorea or erythema. Endocarditis may 
appear alone, being the sole expression at the moment of the rheumatic 
state before arthritis is observed. Endocarditis is constantly over- 
looked because the insignificant joint affection is slight or wanting; 
the child is a little wasted and feverish; but there is nothing to call 
attention to the heart, and thus an insidious inflammation of the 
valves goes on, and is probably not discovered until long after, when 
hypertrophy, dilatation, and loud murmur proclaim its existence. As 
a rule, the endocarditis is subacute, and it is frequently protracted and 
relapsing; "it dies down and revives again." It attacks chiefly the 
mitral valve, but now and again the aortic valves suffer, and in excep- 
tional cases they alone are affected. The first sign and sometimes the 
only sign of the valvular inflammation is said to be a soft blowing 
murmur, usually systolic, at the apex. This may gradually disappear 
after a few weeks, or more often may increase rapidly in distinctness, 
so as to become loud and harsh in the course of a few days. Yet some- 
times the murmur, even if mitral, may be functional, due to temporary 
relaxation of papillary muscles and consequent imperfect closure and 
leakage, and this may disappear as strength and muscular tone return. 
This may, however, be due to valvular inflammation rather than func- 
tional disturbance from paresis ; and the disappearance of the murmur 
should be referred to resolution of the inflammatory process and res- 
toration of the valve to its normal state. A distinct mitral murmur 
is usually organic, indicative of endocarditis, and commonly persistent. 
An aortic regurgitant is invariably organic without exception. 

Pericarditis. — It is thought that pericarditis is less common in the 
rheumatism of children than in adults ; but it is in reality quite fre- 
quent, its occurrence being often overlooked. 

Dr. West 2 records a case of a child seven months old, with post- 
mortem evidence of a previous attack at the age of four months. 
There are, as we see recorded, certain special features connected with 
pericarditis as it occurs in connection with the rheumatism of child- 
hood which we will mention here briefly. In the first place, it is 
thought less liable to occur in the primary attack of articular affection, 
and also, like endocarditis, although it is at times extremely acute, 

ir The collective investigation statistics give in males 72 per cent of heart affection 
in childhood, as compared with 46 per cent in adults. In females the difference is much 
less. 

2 Diseases of Infancy and Childhood, 7th ed., pp. 556, 557. 



Rheumatism. 559 

it is comparatively rare ; and it has a characteristic tendency to become 
subacute, chronic, and intermittent, to smoulder on and then become 
active again, with the advent, perhaps, of a fresh wave of joint affec- 
tion or a fresh eruption of fibrous nodules, or the supervention of 
chorea. Pericarditis, again, though usually associated with joint affec- 
tion, may be the first and only sign of the rheumatic state at the time 
of its occurrence, and be followed by arthritis or other phases of rheu- 
matism at varying intervals ; or it may be the last of the series of rheu- 
matic events. We see statements recorded that, although not rare in 
the early part of rheumatism, it is most commonly observed when the / 
heart has become already greatly enlarged by hypertrophy and dilata- 
tion, and it is then most liable to set up fever and palpitation, with 
excited, turbulent, irregular action of the heart, and quick pulse, 
sometimes excessively so, varying from one hundred and twenty to one 
hundred and sixty even — with cardiac pain, dyspnoea, restlessness, and 
distress. It does not, like endocarditis, leave a record behind it. This 
late pericarditis is frequently the immediate cause of death. 

Pleurisy and Pneumonia. — These stand next to the affections of 
the heart in gravity and importance. They are much less frequent, 
however, and it is doubtful whether pneumonia can claim to be con- 
sidered a certain phase of rheumatism. It occurs chiefly in three con- 
nections, namely, in a limited form as an accompaniment of pleurisy, 
in more extensive degree in relation to, and probably largely dependent 
upon, mitral disease of the heart and pericarditis, and in the embolic 
form also in connection with valvular disease. In the lobar variety 
associated with mitral disease it is almost always on the left side. 

Lebert found that ten per cent of his cases of pleurisy were a 
distinct expression of rheumatism. Like pneumonia, it is most com- 
mon on the left side, and frequently associated with pericarditis. The 
general symptoms of pneumonia occurring in the course of rheumatism 
are usually only a rise of temperature to 103 degrees and 104 degrees 
Fahrenheit perhaps, and somewhat accelerated respiration. There is 
little or no cough, no characteristic rusty sputum as we see in uncom- 
plicated pneumonia, even in the case of adults, nothing to call atten- 
tion specially to the state of the lungs, so that pneumonia is fre- 
quently only discovered accidentally on routine examination, and as 
auscultation of the posterior portion of the chest is often omitted in 
rheumatism on account of the pain it inflicts, the existence of the 
inflammation of the lungs is very liable to escape recognition. The 
physical signs differ somewhat from those of ordinary pneumonia. 
There is bronchial or tubular breathing, but fine crepitation is not com- 
monly found. This crepitation is, however, usually present in the 
limited embolic form. 

Pleurisy and pneumonia, occurring as simple inflammations excited 
by the rheumatic virus, usually resolve quickly, and fluid effused as 
a result of the former is reabsorbed, unless, as in some cases, it becomes 
purulent. But when dependent upon heart-disease it is different. The 



560 Rheumatism. 

pneumonic consolidation and pleuritic effusion are liable to remain, 
or disappear only after a lengthened period. 

Bronchitis. — This is a less frequent symptom, but according to 
Lebert it occurs in nine per cent of cases. 

Tonsillitis. — There is no doubt, according to recorded cases, but 
that children who are prone to articular rheumatism are prone also to 
tonsillitis, nor that it often ushers in an attack of articular rheumatism, 
or occurs during its course. Trousseau recognized a rheumatic sore 
throat. The statistics of the Collective Investigation Committee 1 
shows that tonsillitis occurred as an antecedent to acute articular 
rheumatism in 24.12 per cent of cases, with ten per cent of sore throat 
of uncertain nature. This only gives instances in which tonsillitis 
came first in the rheumatic series; and its full significance is only 
realized when we consider that the throat affection occurs also as a 
later as well as an initial affection, although not so frequently, and 
that it occurs apart from articular symptoms in rheumatic subjects. 
It is not uncommon to see in children who are affected with rheuma- 
tism that the disease is followed immediately after with tonsillitis, 
endocarditis, and chorea. We observe a case reported of a patient 
who had repeated attacks of tonsillitis extending over several years, 
followed by an attack of acute articular rheumatism, which was suc- 
ceeded by chorea and purpuric erythema. So there can be no hesita- 
tion in accepting tonsillitis as a genuine member of the rheumatic 
series. 

Fibrous Nodules. — Drs. Barlow, Warner, and Hill, and some 
German and French observers have drawn attention to the development 
of fibrous nodules in the subcutaneous tissue in connection with rheuma- 
tism. They are extremely common in children, but are rare in adults, 
although cases in grown people have been noticed by Dr. Stephenson, 
'Dr. McKenzie, and Sir Dyce Duckworth. 2 These nodules vary from 
the size of a pin-head to that of an almond or even larger. They are 
tender. They are chiefly in the neighborhood of joints, especially at 
the back of the lebon, about the margin of the patella and the malleoli. 
They are also seen about the vertebral spines, along the clavicle, the 
extensor tendons of the hands and the feet, the pinna of the ear, the 
temporal ridge, and the superior curved lines of the occiput and the 
forehead. They are chiefly confined to the front of the chest, in rela- 
tion to the tendons and fascia of the intercostal muscles. They some- 
times appear in successive crops, sometimes single, sometimes multiple. 
They have been known to develop in ten days ; but they usually take as 
many weeks to subside. There can be no question as to their relation 
to rheumatism. Drs. Barlow and Warner 3 found distinct evidence of 



'Coll. Inr. Record, vol. 4, 1888, p. 70. 

2 Chemical Society's Proceedings, vol. 15, 1883. 

'Trans. International Medical Congress 1881, vol. 4, p. 116. 



Rheumatism. 561 

rheumatism in twenty-five cases out of twenty-seven. Their chief 
association is said to be with endocarditis and pericarditis, and in some 
cases chorea, and frequently with erythema marginatum. 

Erythema. — Exudative erythema appears as one of the phases of 
rheumatism in several of its various forms. Of these, erythema mar- 
ginatum and uticaria are the most common. The former is a frequent 
complication of rheumatism in children, being oftener observed in chil- 
dren than in adults, appearing on the body as well as on the limbs. 

Purpuric Erythema. — This form is said to occur almost exclu- 
sively in young adults ; but it has been seen in cases of young children. 
Dr. Kennicott shows that it is quite distinct from simple purpura. 
The subcutaneous hemorrhages are said to be due to thrombosis of 
small vessels, as in ^blood-poisoning. This is looked upon as consistent 
with the rheumatic condition ; for in rheumatism the blood, as we 
know, is hyperfibrinous, and thrombosis in even large veins occurs dur- 
ing life, and abnormal coagula after death. 

Chorea. — That there is some connection between chorea and 
rheumatism is generally admitted. Many cases, however, of chorea 
can not be traced to rheumatism in origin. Attacks of rheumatism 
may alternate with attacks of chorea. A rheumatic neuritis of nerves 
in the vicinity of the inflamed joint may develop, and pain, numbness, 
or prickling may follow. The muscular atrophy which sometimes fol- 
lows a rheumatic inflammation of the joint is occasionally attributable 
to the associated neuritis. 

Diagnosis. — Difficulty is sometimes experienced, especially in 
young children, in discriminating between acute osteomyelitis and acute 
articular rheumatism, particularly when the former is multiple or in 
the vicinity of the large joints. The intensity of the pain, the extreme 
sensitiveness of the bone, and the typhoidal symptoms are of especial 
importance in the diagnosis of osteomyelitis. Secondary inflamma- 
tions of the joints occurring in the various infectious diseases are pre- 
ceded by the characteristic symptoms of these diseases. In gouty 
arthritis in adults the small joints," especially the great-toe joints, are 
usually affected ; pain and redness are more considerable ; sweating is 
absent ; the fever is slight ; the swollen, tender joints, the profuse sour 
sweating, the mere attitude of the adult patient, lying still and motion- 
less, afraid to move hand or foot, are in themselves almost sufficient 
to distinguish arthritic rheumatism. In children, however, we rarely 
see this extreme typical arthritic form. It is not common in older 
children even before the age of puberty; in very young children it is 
unknown. The diagnosis of rheumatism in early life, when arthritis 
is at its minimum and fever and sweating are not pronounced, is often 
very difficult, and in many cases it is only by a complete and careful 
survey of the whole history of the patient that a correct conclusion 
as to the nature of the attack can be obtained. If the articular affec- 
tion is distinctly manifested, that is, the tender, painful, swollen joints 
with a faint blush of redness on them, perhaps, the tendency to sweat- 

36 



562 Rheumatism. 

ing, the rise of temperature to from 100 degrees to 103 degrees Fahren- 
heit, the shifting of the inflammation from joint to joint, declining in 
a few days and then reappearing, are characteristic. When tenderness 
and swelling are slight, confined to one joint, or there is merely a lit- 
tle stiffness in a tendon, it may be difficult to decide whether the affec- 
tion is really rheumatic or not, although the mere existence of such 
symptoms in a child is very suggestive of rheumatism. Such condi- 
tions are usually rheumatic, and are, it is to be remembered, genuine 
rheumatism, bearing with them all the possibilities of cardiac inflam- 
mation. . The discovery of a fibrous nodule, or the rash of erythema, 
or a mitral murmur, or pericardial or pleuritic friction, or that the 
patient has had a previous attack of rheumatism in any form, or inher- 
ited a family taint of it, will solve the question. All these points 
should be minutely inquired into, and every case carefully examined 
day by day to insure a correct diagnosis. 

There are two affections which are said to have been mistaken for 
acute rheumatism. One is infantile paralysis, and the other, in adult 
cases, pyemia. In case of paralysis in a child, it may be distinguished 
by the flexed muscles, the helpless rolling of the limb on movement, 
the pitiful inability of the child to move except as it is lifted with the 
hand, and the absence of any sign of heart affection or other rheumatic 
symptoms. Pyemia in adults is distinguished by the hectic sweats 
and temperature, by the existence of some local suppuration, and by 
the course of the disease. 

Scrofulous affection of the joints is liable to be mistaken at the 
outset ; but by its steady, unshifting character it is distinguished from 
rheumatism. 

Always in the case of children, whether unmistakable arthritis 
is present or there is merely a stiff and painful tendon, or an unex- 
' plained febrile attack, or chorea, or tonsillitis, or erythema, it is most 
essential to bear in mind the possibility of having to deal with rheuma- 
tism, and to examine the heart carefully day by day ; discover, if possi- 
ble, any cardiac murmur or a friction sound betraying an endocarditis 
or pericarditis, which has never even been suspected, its presence not 
being suggested by any marked fever or ordinary sign of rheumatism. 

Prognosis. — The prognosis of acute rheumatism in a first attack 
is favorable. The general direct mortality, according to statistics, is 
only about three and a half per cent, 1 and it is probably less in children 
than in adults. Fatal cases are due to some of the complications which 
have been enumerated. 

Treatment. — The principles upon which a case of acute rheuma- 
tism with arthritis should be treated at the outset are, first, to prevent 
fresh chill to the surface ; secondly, to keep the affected parts at rest, 
so as to lessen the flow of blood there and the friction of the parts, and 
thus to lighten inflammation and relieve pain (this applies not only to 



l Senator, in Ziemssen's Handbueh, vol. xvi, p. 50. 



Rheumatism. 563 

the joints, but to the heart especially) ; thirdly, by specific remedies to 
modify, if possible, the fever and neutralize the irritant effects of the 
rheumatic poison on the fibrous tissues of joints and tendons; fourthly, 
to prevent, if possible, the inflammation of the endocardium and the 
pericardium, or if this has set in, to minimize and arrest it, and lastly 
to relieve pain directly by anodynes if necessary. 

In acute rheumatism the patient should be dressed in a soft flannel 
nightdress, sleep between all-wool blankets, and be carefully protected 
from draughts of air. In most cases the diet should be restricted to 
milk, when milk agrees, or to raw eggs, with barley, oatmeal, or other 
gruels, the food being given in moderate quantities and at short inter- 
vals. Farinaceous food may be substituted for milk ; Mellin's or other 
similar food is often of service. As the disease advances, the diet 
should be made more sustaining, but too highly nitrogenous food should 
be avoided until convalescence is assured. 

The affected joints may be treated with the galvanic current of 
electricity, the positive pole placed over the inflamed joint or tendon, 
but never the negative pole ; give the strength that the patient can bear 
without too much pain, and very soon after the treatment the pain is 
relieved, and the redness and swelling abate. The seance should be 
not less than fifteen to twenty minutes to each joint. The positive 
pole is to remain about five minutes on each side of the joint, then 
more to the opposite side, etc., till the joint has been treated as above 
prescribed. The negative pole may be placed at some distant part. 
The treatment by the galvanic current is a tedious process, but usually 
two or three treatments, with the salicine medicinal treatment, will soon 
give relief. The galvanic treatment may be given once or twice a day. 
The affected joints, after the treatment and all the time, should be kept 
wrapped in wool batting (cotton batting does very well), and should be 
kept as quiet as possible by the means of sandbags, or a close and well- 
fitting splint, not tightly bandaged. 

Various local applications have been prescribed by different 
authors, which I shall mention. The application of cold in the form 
of water-dressing is advocated by Senator, or of ice by Esmarch, but 
of this practise I have had no experience. The application of blisters 
has been highly recommended for the relief of pain. Simple warm 
water, concentrated solution of sodium-bicarbonate (1 to 10 of water), 
or diluted tincture of aconite and laudanum, saturated solution of 
ammonium chloride, or Fuller's lotion (sodium carbonate, six drachms; 
tinctura opii, one ounce; glycerine, two ounces; water, nine ounces), 
are among the effective lotions. (Fitz.) 

Another plan which has been highly commended for the relief of 
pain is the hypodermic injection of a one per cent solution of carbolic 
acid under the skin over the affected joints, and the application of car- 
bolized oil (1 to 15). 

There are two, more or less, specifics for the treatment of acute 
rheumatism. The older of these is the use of alkaline potassium salts. 



564 Rheumatism. 

In carrying out this alkaline treatment for adults, one ounce of the 
potassium salts dissolved in at least one pint of warm water is to be 
divided into equal doses and given during the twenty-four hours. As 
the potassium citrate is converted in the system into potassium car- 
bonate, it is much less disagreeable to the palate and less irritating to 
the stomach than the carbonates; hence it is preferred. 

The citrate of potassium may be given in lemonade ; the lemonade 
assists in its action; it must be taken in dram doses in half an ounce 
of lemon- juice put into a glass of water for each dose, and diluted at 
the time of taking with carbonic-acid water from a siphon. After 
from three to seven days it is necessary to lessen the dose of the potas- 
sium salt, on account of its depressing influence. (Wood.) 

We have had more experience with the salicylic-acid treatment, 
or salicylate of sodium, or oil of wintergreen. The ammonium salic- 
ylate or acid salicylate may be administered in capsules. The sodium 
salicylate may be administered in cold water with the white of an 
egg dropped into the solution, which prevents nausea and is not disagree- 
able to the palate. It rarely ever fails to bring down the temperature 
and relieve the pain of rheumatism in the course of twenty-four to 
forty-eight hours. But there are several drawbacks to its use. Because 
it sometimes sets up nausea and vomiting, it has a depressing effect 
upon the heart, the pulse loses strength, and the first sound of the heart 
becomes faint when it is given in large doses. It produces ringing in 
the ears, slight deafness, and vertigo. In large doses it may cause 
violent delirium, albuminuria, and collapse. These results occur much 
less frequently in children than in adults ; yet in view of the proneness 
to heart affection in the young, it is well to use a depressant drug with 
great caution. The salicylate of sodium is the best preparation. Given 
in small doses to children with joint affection accompanied by fever, it 
will reduce the temperature more quickly than any other remedy. 
Give the salicylate of sodium for the first twenty-four hours, then 
replace it with salicine as a substitute; for salicine has little if any of 
the evil properties of salicylate of soda, due probably to its very gradual 
passage into the circulation, and producing its effects more slowly. 
Salicine is highly recommended in all cases except the most severe, then 
preferably the sodium salicylate, which may be given from two to five 
grains every three or four hours to a child five years of age, mixed with 
water and syrup of orange. 

The salicine should be continued in less frequent doses for some 
days after all symptoms have ceased, or a relapse is liable to occur. 
These remedies will serve the purpose of reducing the temperature and 
the arthritis, but unfortunately they seem neither to prevent the occur- 
rence of carditis nor to arrest or modify it when developed. Accord- 
ing to recent statistics of the Collective Investigation Eeport, alkalies 
should be given in combination with salicine, and salts of soda in prefer- 
ence to those of potash, as being less depressant. The dose — equal 
parts of salicine, salicylate of soda, and bicarbonate of soda — is from 



Rheumatism. 565 

six to ten grains. The amount of alkali must be regulated, by the state 
of the urine ; enough should be given to keep it neutral or slightly alka- 
line. If, however, endocarditis or pericarditis come on, the salicylates 
or salicine should be at once stopped, and the alkali given in freer 
doses, ten to fifteen grains every four hours, with half a drachm of 
syrup in half an ounce of water. In severe cases of endocarditis and 
distress, quinine should be given in addition, in doses of two to three 
grains every four hours for a child five years old. Where the fever 
runs high, and where there is palpitation and cardiac dyspnoea, this may 
be given in ten-grain doses of citrate of soda, two grains of quinine, and 
five grains of citric acid, or acid hydrobromate of quinine may be 
given every four hours alternately with the alkali. This salt is 
extremely soluble (ten grains to one drachm), so that the dose can be 
administered in a single teaspoonf ul of water ; and it has also the 
advantage of being less liable to cause sickness than the sulphate. 
Adults may increase the dose of the above for like conditions to suit 
the age. 

Many other drugs have been used in the treatment of rhemnatism, 
which are much less useful, and some of them harmful or even dan- 
gerous. Among the latter may be mentioned antimony, aconite, and 
veratria ; all of these are heart depressants, which makes their use 
negative in this disease, especially in children. Colchicum has not 
the same specific influence in rheumatism as it has in gout. 

Iodide of potassium is quite insufficient ; when given with salicy- 
late, it seems, according to the report in the Collective Statistics referred 
to, to retard the effect of the salicylate, i^itre and lemon-juice have 
been highly extolled, but have proved to be distinctly inferior to salicine, 
the salicylates, and alkalies. Antipyrine, given in cases of high temper- 
ature, has proved to be beneficial in reducing the temperature, given 
in doses according to the age of the patient ; antif ebrine, also, is said 
to be useful, equally as good results following its use as that of anti- 
pyrine. The writer has never had any experience with this remedy in 
rheumatic cases. We see reported cases of serious syncopal attacks 
occurring in adults, and I should hesitate to use them at all freely with 
little children. 

Salol is recommended by some practitioners, and others condemn 
its use. The writer has found it beneficial in joint affections in con- 
sumptive cases, giving satisfactory results. In endocarditis or pericar- 
ditis in children, when the action of the heart is rapid and turbulent, 
one to two drops of tincture of digitalis may be given every four hours 
to a child five years of age for twelve to twenty-four hours, after which 
time it may be given only two or three times a day. This remedy 
must be administered with caution ; it is a dangerous remedy when 
there is much pericardial effusion, or if the heart is thickened, with an 
adherent pericardium. When the palpitation is due to feebleness or 
dilatation, digitalis has great power to steady and give tone and force 
to the cardiac contraction. While stimulants should be avoided if 



566 - Rheumatism. 

possible in dilatation and palpitation of the heart, yet sometimes it 
is necessary to use a little wine or brandy when signs of heart failure 
appear. In such cases they may be given freely to the amount of three 
ounces of wine and one and a half ounces of brandy in twenty-four 
hours. Alcohol is wonderfully well borne by children ; and it is to be 
noted that it produces little or no excitement, but acts rather as a 
sedative. A remedy of immense value in most stages and forms of 
rheumatic fever is opium. It may be required to ease pain and rest- 
lessness and produce sleep. It is recommended to be given freely in 
doses of one to two minims every four hours for a child five years of 
age, if there is no concurrent pneumonia or bronchitis. The vomiting 
which sets in at the close of pericarditis should be combated with ice 
and small doses of hydro-cyanic acid and soda, with nutrient 
enemata for twelve hours, taking no food by the mouth. If chorea is 
severe, bromide of potassium and chloral hydrate may be given in four- 
grain doses in sweetened water every four hours, according to age, till 
drowsiness comes on. 

When the temperature has been down for a week, iron should be 
administered for the anemia, which, as has been stated already, is so 
marked in the rheumatism of children. The citrate of iron in doses of 
three to five grains with ten grains of citrate of soda and syrup of ginger 
or orange, in half an ounce of water, should be given as a precaution 
against relapse, especially in cardiac inflammation; or citrate of iron 
and quinine, two to four grains, to suit the age, with citrate of soda or 
potash, may be given in the same way with lemon-juice or syrup of 
lemon. If the anemia is extreme, or the chronic symptoms persist, 
arsenic should be administered with the iron, Fowler s solution, one or 
two drops of liquor potassii arsenitis, put in two drams of wine of iron, 
night and morning after food. This is said to be the most efficient of all 
drugs in the restoration of red blood-corpuscles. It should not, how- 
ever, be prescribed until all symptoms of active inflammation are over ; 
for it stirs up hyperemia in the skin and mucous membrane, as evi- 
denced by the redness of the conjunctiva and tongue, and the flushing 
of the skin produced by full doses of the drug, and it may presumably 
affect fibrous structures and serous membranes in like manner. 

The erythema goes with the subsidence of other symptoms, and 
requires, as a rule, no special treatment. Tonsillitis yields to salicy- 
lates and salicin with great readiness. 

The diet in cases of rheumatism depends upon the general con- 
stitutional condition. When the temperature is raised, and acute 
symptoms are present, it should consist entirely of beef tea and broths 
with milk, if it agrees, and raw eggs. In cases of great anemia or pros- 
tration, Valentine's meat juice is recommended by some authors, or 
even raw-meat pulp, if it can be taken ; these should be given as blood 
restorers. As the fever declines, light pudding, bread and butter, and 
tea may be permitted ; and the patient may soon take fish or meat. 

Large quantities of sugar should be withheld, as it tends to favor 



Rheumatism. 567 

lactic fermentation. The patient should rest in bed for at least ten 
days or two weeks after all acute symptoms abate, so as to insure against 
a relapse or a chill, and extreme quietness prevents cardiac disturbances. 
Prevention. — A child who has ever had acute rheumatism is 
prone to a recurrence of the disease. As age increases, however, the 
tendency gradually becomes less. A child born of rheumatic stock has 
also a special liability to rheumatism. In both cases precautions should 
be taken to protect those who are thus predisposed from overheating, 
chilly and overfatigue, the great causes of rheumatism. To this end 
the child should not be kept too tenderly, but should be out of the hot, 
close rooms, should live in a cool and even temperature, should wear 
woolen next the skin, while the body is hardened by tepid salt-water 
baths and vigorous friction. In case of accidental exposure to cold or 
wet, brisk exercise should be taken until a full glow of warmth is 
experienced, and damp clothing changed at the earliest moment. Sud- 
den changes of temperature should be carefully avoided, and when 
overheated the body should be protected against chill by extra covering 
until it cools down again. Damp air, cold soil, and variable climate 
should be avoided if possible. When circumstances permit, the rheu- 
matic child should be removed to a dry, warm climate, with sandy soil, 
in a situation not overcrowded with trees, exposed to sunlight, and with 
a free circulation of air. 

CHRONIC RHEUMATISM. 

Chronic rheumatism is rare in children, much more rare than in 
adults. It is to be distinguished from the relapsing form of acute 
rheumatism, where fresh exacerbations of a mild kind, sometimes 
nothing more than a stiffness and vague pains without swelling, recur 
from time to time. But in certain cases affections of the joints, such 
as effusions or ankylosis, do remain in chronic form after an acute 
attack. The writer had two cases of chronic rheumatism of a long 
formation in the muscles and tendbns of the ankle joint, rendering the 
movement of the ankle painful and difficult. Both patients were born 
of rheumatic parents. I remove each bony mass with the galvanic 
current of electricity, with very high amperage, to the strength of mak- 
ing a scar on the bony mass. The current must be applied by placing 
both poles on each side of the mass very close against the growth, for 
at least ten minutes in a place ; move the poles the second time in order 
to treat the affected part all around. It may be necessary to use cocaine 
in order to give a current strong enough to stop the growth ; then nature 
soon absorbs. In one case I gave only six seances, two a week. The 
other was given a dozen treatments ; in each case the galvanic current 
was perfectly effectual. In each case I prescribed a constitutional 
treatment of iron and iodide of potash, put up in comp. syr. sarsaparilla, 
given in small doses. For very chronic cases, in addition to the gal- 
vanic current of electricity, baths are very beneficial. Hot springs of 
any kind afford the most hopeful treatment. Hot brine baths are use- 



568 Rheumatism. 

fill in many cases, or the simple warm baths are used for the promo- 
tion of absorption or relief of pain. Wrapping the joints in wool 
impregnated with linseed oil and a little carbolic acid and oil of tur- 
pentine, which keeps up a mild constant stimulation, is an excellent 
plan in most chronic cases. Pine oil alone is recommended by some 
writers, being useful in slighter cases. Tincture of iodine, as a 
counter-irritant, painted over the joints, has been used with considerable 
benefit in many cases. Stimulating liniments are also very useful. 
The following liniment has proved useful in the writer's hands: — 

1$: Oil wintergreen 3\v 

Tinct. aconite 3ij 

01. capsicum £iij 

Tinct, opii, 

Tinct. belladon., aa 3iv 

Tincture arnica, ad. q. s 3viii 

M. et sig. : Shake the bottle before using it. Apply night and 
morning over the seat of pain; then put on wool or cotton batting. 
Massage and electricity are good in all forms of chronic rheumatism. 

GONORRHEAL RHEUMATISM. 

A title applied to the occurrence of symptoms of acute articular 
rheumatism, but due to gonorrhoea! infection. Especial importance is 
to be attached to the occurrence of such symptoms from infection by 
gonococci, from the close resemblance which they bear to the symptoms 
in rheumatic fever. 

Etiology. — Petrone and Kansmerer have shown, by the repeated 
recognition of the presence of gonococci in the fluid from inflamed 
joints, in the pus from the tendon-sheaths, by their presence in the dis- 
ease valves in acute ulcerative endocarditis (Leyden), and their dis- 
covery by Councilman in myocardial abscesses, that such a disease exists. 
Olser records that gonococci were cultivated from the blood of a patient 
with a malignant endocarditis, and others have reported the presence 
of gonococci in the blood. Men are oftener affected than women, and 
urethral or vaginal gonorrhoea is the usual means of affection. Gonor- 
rhoeal ophthalmia and vulvo-vaginal catarrh in infants and children may 
also be followed by gonorrhoeal rheumatism. 

Symptoms. — There is said to be no essential difference between the 
symptoms of acute articular rheumatism and those of gonorrhoeal 
rheumatism, with the exception that in the latter they are less severe 
and more obstinate. The disease may be indicated by fleeting pains in 
the vicinity of the joints without fever, or by moderate redness, swell- 
ing, and pain of one or more joints, with slight elevation of temperature. 
In other cases sudden inflammation of the joints occurs, with severe 
pain and marked swelling, especially in the knee-joint, but with mod- 
erate fever. The symptoms usually extend over a period of weeks or 
months, with exacerbations and remissions and passible complications, 



Rheumatism. 569 

as endocarditis, pericarditis, pleurisy, or entritis. The local inflam- 
mations ordinarily terminate in resolution, but when suppuration takes 
place, adhesions may occur, with permanent deformity. The prognosis 
is said to be generally favorable. 

Diagnosis. — In obscure cases (in adults) of gleet, a gonococcal 
cause for the rheumatic symptoms may be overlooked ; and a gonorrheal 
cause may be assumed for the rheumatic symptoms provided a recent 
infection has occurred. It is stated that in general fewer joints are 
affected in gonorrheal rheumatism, the fever and pain are less extreme, 
the swelling persists longer, and anti-rheumatic treatment is of but little 
avail. 

Treatment. — The Hot Springs in Arkansas are undoubtedly very 
beneficial in chronic cases. The hot mineral baths and the climate seem 
to have a decided curative effect upon such cases. The galvanic current 
of electricity, with very high amperage, does aid in the cure of the dis- 
ease. It should be applied through the joint by placing an electrode 
on both sides of the joint, and treatment should be given from fifteen to 
thirty minutes to each joint. It must be given as strong as can be borne. 
It may be given daily at first, later on every other day. Wood states 
that in the acute cases, rest, fixation of the joints by splints, and blis- 
ters, or the application of thermocautery over the joints, constitute the 
major part of the treatment. The writer has found the galvanic slight 
chemical blister to be very beneficial. It may be necessary to apply a 
twenty per cent solution of cocaine to the joint by means of absorbent 
cotton dipped in cocaine and laid over the joint ; place the electrodes 
over the cotton; in this way, the current can be borne strong enough 
to blister. The joint may be treated all around and on top ; the elec- 
trodes must be moved over the joint till every part of it has had the 
action of galvanism. In chronic cases the administration of tonics, 
with good food, careful attention to hygienic surrounding, and the use 
of massage and passive movements, is necessary for the cure of these 
cases. 

Local treatment of the genito-urinary organs (see gonorrhea in 
women) may be persevered in. The surgical treatment of inflamed 
joints by opening and irrigation, is said to have yielded satisfactory 
results. 

CHRONIC ARTICULAR RHEUMATISM (CHRONIC RHEUMATIC ARTHRITIS). 

Definition. — This is a chronic disease of the joints characterized 
by slow inflammatory and degenerative changes of the articular struc- 
tures, and leading to distortion and other deformities. It is most fre- 
quent in adults after middle life. It occurs at all seasons of the year, 
lien are more prone to the disease than women. Garrod states that 
he has seen it in its severest form in children of ten and twelve years of 
age. 

Symptoms. — In children, as a rule, the disease exhibits no special 
features. It is associated with the smaller joints of the extremities. 



570 Rheumatism. 

It begins in the same way as in adults, with fugitive articular pains, 
then stiffness; especially after the joints have not been moved for some 
time, as during the night or the first thing in the morning, they will be 
found stiff and sore on moving. The pain and stiffness are more pro- 
nounced and more severe in wet weather, also in low foggy weather. 
The stiffness is not noticed much in the middle part of the day, but 
becomes persistent towards evening. Acute exacerbation of the joint 
may occur, associated with slight fever, making rest necessary. The 
longer the inflammation persists, the more likely are the joints to 
creak on motion, and the degree of motion is more and more impaired. 
The extremities are often flexed in various degrees; the rigidity is 
only partially overcome by passive motion, and in extreme cases the 
sufferer is bedridden, and often extremely emaciated. Several joints, 
both large and small, are usually affected in adults, and the symptoms 
of the disease rarely disappear. Complications are rare. 

Diagnosis. — It is extremely difficult to distinguish rheumatoid 
arthritis from the more chronic or subacute forms of genuine rheuma- 
tism until the characteristic deformities have been developed. When 
the enlargements of the joints, the crepitus on movement, the wasting 
of muscles, the thin, glossy skin, and the distortion of the fingers arise, 
there is no difficulty in confirming the true diagnosis. 

Prognosis. — Cases of this kind are so rare in children that but 
scanty means of forming a judgment as to its course and issue are 
available. The prognosis is said to be more favorable in a child than 
in adults. But in the more severe forms, rheumatoid arthritis is as 
persistent in children as with adults, although it can be modified by 
treatment, and is attended with no immediate danger to life. 

Treatment. — Everything which tends to improve the health — good 
nutrition, warm, dry, sunny climate, and warm clothing — is of the first 
importance. The affection being especially associated with enfeebled 
general health, all lowering or drastic purgative treatment is useless 
and positively injurious. Mistakes have been made in the diagnosis 
of rheumatoid arthritis, and a low diet, purges, alkalies, and colchicum 
prescribed, on the supposition that the disease to be dealt with was true 
gout, or genuine rheumatism, and detriment to the patient resulted ; and, 
on the other hand, generous diet, good tonics, and hygienic surround- 
ings soon improved the patient's condition remarkably. The joints in 
rheumatoid arthritis will not improve under irritating treatment, as 
blistering or strong stimulating liniments. Gentle rubbing and exer- 
cise of the joints keeps them from stiffness. The galvanic current, 
using the positive electrode over the seat of affection and the negative 
pole some distance from the positive, is very beneficial in preventing 
stiffness. It should be applied two or three times a week. In some 
cases of poor constitution, iodide of potash and arsenic are effectual, — 
three grains of the iodide of potassium and two or three drops of 
Fowler's solution of arsenic, to be taken night and morning after meals. 
For children, Wampole's cod-liver oil may be advantageous. But the 



Rheumatism. 571 

hot baths and hot, dry-air treatment are beneficial in many cases. Hot 
sulphur baths are beneficial. The natural warm sulphur springs are 
the best, but if circumstances will not permit of the patient going to 
these springs, a sulphur bath made by adding four ounces of sulphur or 
sulphate of potassium to thirty gallons of warm water, often answers 
the purpose sufficiently well. Strumpell very strongly recommends hot 
sand baths. Hot salt baths, followed by Swedish movements, are very 
useful in most cases. 



CHAPTEE XLIII. 
CHOLEEA, OE CHOLEEA ASIATICA. 

Definition. — This is a contagious disease, produced by the coma 
bacillus of Koch, capable of being transported from place to place, 
and under favorable circumstances, endowed with the power of rapid 
multiplication, both within and without the human organism. It is 
characterized by violent serous purging and cramping, rapidly followed 
by collapse. 

Etiology. — Asiatic cholera is endemic in India. It is said always 
to exist in India; indeed, apparently it is the chief instrumentality in 
keeping down the surplus population, having, according to Annesley, 
between 1817 and 1884 destroyed eighteen millions of Hindoos. Chol- 
era travels with the people. "In 1884 Koch discovered the cause of 
cholera, an actively motile, flagellate, curved bacillus, the 'comma 
bacillus/ which is about half the length of the bacillus of tuberculosis 
and is considerably thicker. According to the observation of Hueppe, 
frequently two small, spherical bodies form in a spiral thread, and 
continue to increase in number until the whole thread is resolved into 
minute round cells, cohering by a jelly. These so-called 'arthro- 
spores' resist desiccation and other injurious influences much better 
than does the comma bacillus, and under favorable circumstances 
develop into the comma bacillus. They appear, therefore, to be a 
permanent form of cholera organism, and it is probably through this 
influence that the disease is spread. The cholera organism develops 
rapidly in sterilized water, in milk, and various organic solutions, pro- 
vided these be not acid. It is easily destroyed by various bacteria, 
by acids, by germicides, and by a temperature of 130° Fahrenheit. It 
exists in immense quantities in the alvine discharges of cholera patients, 
and has been detected in drinking water, milk, and various foods. 
The comma bacilli are never found in the blood or general tissues,, 
although they enter the epithelial cells and basement of the intestines. 
As the comma bacillus exists in the human body only in the primia? 
vise, escapes from the human body only with the alvine discharges, and 
is capable of producing cholera when injected hypodermically, infec- 
tion must take place through the mouth. For such infection it is neces- 
sary for drinking water, food, or other medium of transmission to 
become contaminated, directly or indirectly, with the alvine discharges. " 
(Wood.) 

Symptomatology . — The incubation period of cholera varies from a 
few hours to as many days, according to the stage, character, and rapid- 
(572) 



Cholera , or Cholera Asiatica. 573 

ity of the attack. Clinicians who have treated this disease have gen- 
erally recognized four stages: First, of premonitory diarrhea; second, 
01 serous diarrhea ; third, of collapse, algidity, or asphyxia ; fourth, of 
reaction. It is said that in most epidemics of cholera, perhaps the 
majority of sufferers experienced the so-called premonitory diarrhea, yet 
observers have repeatedly noticed its general absence. And, again, it 
is stated that where such diarrheas have been widely prevalent, com- 
mon experience has shown that only a comparatively small percentage 
develop into recognized choleraic attacks. If the premonitory diarrhea 
indicates a genuine invasion of the organism by the specific infection 
of the disease, certain it is that there are many grave and fatal attacks 
without its presence. But it is in the experience of all who have had 
much to do with epidemics of cholera that any one of the recognized 
stages of the disease may be wanting. It therefore seems unwarrant- 
able, on the ground of its frequent absence, to exclude the first stage of 
premonitory diarrhea as a part of the real disease. Some authors think 
that from the therapeutical standpoint it is wise to treat this stage as 
the commencement of the attack of cholera, which, if neglected at this 
time, may ultimately have a fatal termination. If the diarrhea is not 
controlled, it may, after persisting for hours or days, be followed by 
epidemic, or the commencement of the attack of the dreaded disease. 
It is during the night that this onset occurs in the majority of cases. 
The second stage is the symptom which, with its usual accompaniments 
of intense thirst; nausea or vomiting; cold, shrunken, wrinkled skin; 
sunken eyeballs ; husky voice ; weak, frequent pulse ; great prostration ; 
restlessness ; anxiety ; and cramps, by far the most frequently marks, 
l)oth for the family of the sufferer and for the physician, the commence- 
ment of the feared attack. If the diarrhea has been present, the alvine 
discharges undergo usually a striking and more or less characteristic 
change, and often become much more copious and frequent. Up to this 
point the disease has been essentially localized, and the intensity of 
action of the specific poison has fallen upon the lining of the intestinal 
canal. The intestinal epithelia lose their functions and vitality, and 
desquamate in flakes. 

With the desquamated flakes of epithelia, the lumen of the intes- 
tines now contains serous fluid exuded from the paralyzed capillaries. 
The intestinal contents are free of bile, resemble a more or less thick 
meal gruel, or macaroni, or rice-water, and the alvine evacuations pre- 
sent the well-known appearance of such material, but often somewhat 
foamy, and they are strongly alkaline in reaction. Besides the symp- 
toms above indicated, any of which may be wanting or but slightly pro- 
uounced, there is more or less suppression of the urine. It is said 
while serous diarrhea is customarily an exceedingly prominent symptom 
in cholera infectiosa, yet there are genuine cases of the disease where 
it is totally absent, the so-called cases of cholera sicca, dry cholera. In 
these cases, although there may be no diarrhea at all, the autopsy shows 
almost invariably an enormous quantity of the grumous fluid retained in 



574 Cholera, or Cholera Asiatica. 

the intestinal canal, which it distends. Moreover, instead of a colorless 
material there may be a yellowish or even a bloody tinge, and there 
may be a certain admixture of ordinary intestinal contents. The intel- 
lect is generally clear. 

The third stage of serous diarrhea, or rice-water discharges from 
the bowels, with the accompanying symptoms, lasts for a variable period 
of two or three to several hours. Reaction may occur at the end, or, 
what is more frequently the case, collapse may set in. In this stage 
vomiting ceases, the serous discharges are interrupted, or the contents 
of the intestines dribble away unceasingly and involuntarily. The 
heart almost stops its pulsations; the thickened blood almost ceases to 
flow^; respiration becomes extremely shallow, slow, and irregular; 
aphonia is complete, as also is anuria; the surface is cold as marble, 
and livid, especially that of the orbit, nose, lips, fingers, and toes. Even 
the tongue and breath are cold. This stage may last for several hours, 
to end in death or reaction. It is said, notwithstanding the striking 
coldness of the cutaneous surfaces, the temperature of the rectum is 
higher than in health, and in some cases is greatly elevated ; the patient 
is usually sensible of the most consuming internal heat. And if death 
supervenes during these stages, the temperature of the corpse may 
ascend several degrees above the normal body heat, and remain there 
for some hours. 

The fourth stage of reaction succeeds that of serous diarrhea or 
of collapse. In the most fortunate cases, convalescence begins at once, 
and proceeds regularly to the rapid restoration of health, with the 
appearance of bile and of normal fgeces in the intestinal canal. But if 
there has been great destruction of the intestinal epithelia and of the 
subjacent connective tissue of the mucosa, there may be prolonged 
ansemia, with all its usual sequences, or there may be a long-continued 
series of digestive derangements, and in either a very tardy reestablish- 
ment of health; or the patient may unfortunately pass into a typhoid 
condition of reactionary septic fever. 

Complications and Sequelae. — Various cutaneous eruptions, as ute- 
caria, erythema, or roseola, develop during the period of reaction in 
about four per cent of the cases. More serious are the pneumonias and 
other pulmonic complications, which are not rare. Convalescence is 
usually protracted, and most always accompanied by dyspepsia and 
often by rebellious diarrhea. Neuritis, tetany, especially after child- 
birth, forunculosis, and glycosuria, are among the sequela? which occa- 
sionally are said to occur, besides those already noted, according to the 
character, gravity, and rapidity of the attack. 

The mildest forms of cholera are those which are known as choler- 
ine, which are without the development of the stage of collapse or 
typhoid reaction. The term foudroyan is applied to those exceedingly 
rapid and grave cases which run their course from beginning to end in 
a very few hours. In cholera toxica there seems but little evidence of 
localization of the initial attack upon the intestinal canal, but the 



Cholera, or Cholera Asiatica. 575 

nervous centers and great internal organs are quickly overwhelmed 
with toxic quantities of the poison. 

Diagnosis. — During an epidemic of cholera every case of serous 
diarrhea should be considered as one of cholera, and so treated with the 
utmost care. So far as symptoms are concerned, there is no difference 
between cholera, cholera nostras, and various metallic poisonings, not- 
ably the antimonial and arsenical; the finding the comma bacillus is 
the only complete evidence to base the diagnosis upon. 

Prognosis.- — "In the beginning of an epidemic of cholera the mor- 
tality usually ranges from forty to even seventy per cent ; but as the 
epidemic progresses, either because the pathogenic agent loses its viru- 
lence, or because it is the most susceptible who are first attacked, the 
fatality steadily diminishes. In individual cases, prognosis must 
always be guarded, since the mildest form of diarrhea may suddenly 
develop an irresistible force, while, on the other hand, it is not rare for 
patients to react from the most desperate conditions. During the 
period of reaction any irregular symptoms or any appearance of cere- 
bral or pulmonary complications is of the gravest import. The very 
young, the very old, the alcoholic, the insane, and persons weakened by 
previous chronic disease, all die in large proportions." 

Prophylaxis. — From the nature and life history of the cause of 
cholera, it is obvious that absolute shutting out of the germ by quaran- 
tine will be necessary to prevent the spread of the disease. Absolute 
cleanliness will aid in arresting the spread of the disease, but will not 
atone for carelessness in allowing the escape of the germ. In no other 
disease is personal prophylaxis so effective as in cholera. For personal 
infection it is necessary that the germ be taken into the mouth and into 
the stomach, so that theoretically it is possible to live in daily contact 
with cholera patients without evil results. The precaution requires 
absolute vigilance in every care and respect ; there must be no weak- 
ness in any point or particular manner, as it may nullify the value of 
the whole procedure. The hands and finger nails must be kept free 
from contamination by frequent washings. They should be kept 
trimmed close to prevent the lodgment of the comma bacillus. The bed- 
ding and clothing must be thoroughly washed and disinfected. (See 
Typhoid Fever.) The food must be eaten directly after it has been 
disinfected by fire. The diet should be restricted to meats, hot bread, 
hot cakes, or hot toast, and such articles as shall come from the fire 
directly to the table, and be eaten as hot as can be borne by the palate. 
All indigestible food should be avoided. Eo water should be taken 
except that which has been boiled and is still hot, or that which has 
immediately been taken out of bottles into which it was put before the 
epidemic. It is essential that all dishes be heated before serving the 
food. Some years ago, we see it recorded, a violent outbreak of cholera 
in the insane department of the Philadelphia Almshouse was arrested 
within twelve hours, without the precautions just spoken of, by the 
free administration of sulphuric-acid lemonade. The only new case 



-576 Cholera, or Cholera Asiatica. 

was that of a man who refused the prophylactic. In the surgical wards 
of the same institution the acid was used from the beginning of the 
epidemic, and in these wards, although in no way isolated from the 
oilier departments, there was absolute freedom from the disease. The 
hygienic condition of dwellings and their surroundings should be made 
as perfect as possible. All decayed animal or vegetable matter should 
be removed. The cesspits and privies should be kept clean and free 
from odor by the use of unslaked lime or large quantities of copperas. 
When a person is suffering from an attack of the disease, the evac- 
uations from the stomach and bowels should be immediately disinfected. 
The dejecta and vomited matter should be passed into a vessel containing 
a qfuart or more of a strong carbolic-acid solution, one part of acid and 
twenty of water, and immediately after the evacuation a sufficient 
amount of the disinfectant should be added to make the whole quantity 
equal to the bulk of the evacuated material ; the whole should be stirred 
gently, and afterwards allowed to stand for ten or fifteen minutes, when 
it should be emptied into the pit or privy. The privy should contain 
plenty of unslaked lime. Bichloride of mercury is preferable to car- 
bolic acid, — one part of bichloride of mercury to one thousand parts of 
water. Immediately after removal the clothing and bed linen should 
be disinfected, by being soaked for an hour or more in the bichloride 
solution or carbolic-acid solution, one part to twenty, or they should be 
immediately boiled after removing them from the patient. The arms, 
hands, and mouth of the patient should also be immediately washed 
after an evacuation, with bichloride of mercury solution for the arms 
and hands, and sulphuric, used diluted, to wash the mouth. The hands 
of the attendant should also be washed with a weak solution of bichloride 
of mercury. Under no circumstances should the attendant, or any one 
else, eat in the sick-room ; no person who has been in direct contact with 
.the sick or with any of his personal effects, should eat without first 
thoroughly cleansing and disinfecting the hands. 

With regard to a healthy person exposed to the infectious prin- 
ciple of the disease, all irreg? tlarities of . personal habits should be 
avoided, either as to time of meals, occupation, exercise, or hours of 
sleep ; all emotional excitement should be removed ;' in short, every cir- 
cumstance which experience has shown may exercise a disturbing 
influence upon these important functions should be carefully guarded 
against. The use of articles of food which are liable to disturb the 
digestive apparatus must be avoided. The child should be carefully 
shielded against intemperate weather; it is all-important that the func- 
tions of the skin should be kept regular and active by a sufficient amount 
of clothing suitable to the season of the year. Cold baths should be 
avoided. Particular care should be taken that revulsions of blood, pro- 
duced by chills, from the cutaneous surface to the internal organs, 
especially the abdominal, may not occur, and in connection with this it 
is strongly recommended that a broad flannel band be worn during 
sleep, because through restlessness the child might become exposed 



Cholera, or Cholera Asiatica. 577 

while sleeping. Sponge the body with tepid water, drying quickly with 
a coarse, soft towel. A child should on no account be permitted to 
occupy the same bed with a sick person, and should be kept as much as 
possible from the sick-chamber. 

Treatment. — During an epidemic of cholera, every case of diar- 
rhea must be treated with the greatest care, and most cases can be 
arrested before the cholera bacillus has full possession of the alimentary 
canal. Put the patient to bed, and confine him to a special diet of 
meat essences and strong broths, and give the doses of aromatic sul- 
phuric acid, for an adult as follows: — 

Jfc: Acidi sulphurici aromatici f3ij 

Ext. hsematoxyli 5iij 

Syr. zingiberis fgjss 

Misce et adde. 

Tr. opii camphorated , . ..^jss 

Sig. : Dessertspoonful for an adult ; give to child dose suitable to 
age. 

In many cases it may be necessary to diminish the amount of pare- 
goric, and increase the amount of syrup of ginger proportionately. It 
is recorded that washing out the bowels thoroughly with distinctly 
acidulated water has proved beneficial. Hayem recommends lactic 
acid, ^.ve drams in twenty-four hours, in cholera, or as a prophylactic 
a dram and a half used daily, well diluted, in divided doses of four, 
in twenty-four hours. The aromatic sulphuric acid has an advantage 
on account of its astringent action. Naphthol, strontium, salicylate, bis- 
muth subnitrate, and other intestinal antiseptics should be used freely. 
Bismuth salicylate is particularly commended by some French authors. 
But the enteroclysis of tannic acid, introduced by Professor Cau- 
tani, of Naples, and so frequently used by Italian physicans during 
the recent cholera epidemic in Italy, would seem to afford the greatest 
reliance in the treatment both of the premonitory diarrhea and of the 
active stages of the disease. If a slight attack of seemingly simple 
diarrhea does not yield at once to rest in bed and the administration of 
a dose or two of warm infusion of chamomile, to which chlorodyne or 
laudanum has been added in proper quantity, suited to the age of the 
patient, at proper intervals; then recourse should be had without loss 
of time to the warm enteroclysis of tannic acid. This enteroclysis is 
essentially an injection into the colon per rectum, through a long rub- 
ber tube, of a considerable quantity of warm water, containing a certain 
percentage of tannin, as follows: — 

Ijfc: Boiled water or infusion of chamomile.. 2 litteri 

Tannic acid 5 to 10 grains 

Laudanum 30 to 50 drops 

Powdered gum-arabic 50 grams 

The temperature of the mixture should be blood heat. The quan- 
tity to be injected should vary with the age of the patient and other 

37 



578 Cholera, or Cholera Asiatica. 

circumstances according to the judgment of the attending physician. 
The most convenient time for administering the injection is imme- 
diately after an evacuation of the bowels. 

In the language of Kamello, "If all of those who suffer from diar- 
rhea in time of cholera would at once have recourse to tannic enterocly- 
sters, the grave cases of this disease would be very rare." But so often 
the physician is not called in time to use this highly-recommended 
prophylaxis. When the patient is first seen, he has generally passed 
far towards a collapse, or is already in a stage of collapse, when the 
system is nearly overwhelmed by the quantity of the poison already 
absorbed from the intestinal canal and by the excrementitious substances 
retained in the economy through failure of the liver and kidneys to 
perform their excretory functions, and when neither the substances 
swallowed per mouth nor those injected per rectum, are longer absorbed. 

In this desperate condition, the warm bath, repeated every hour or 
two, is said to be of some benefit. But it should be supplemented by 
an attempt to restore to the tissues of the body the large quantities of 
the fluids which have been lost, and to wash out from them some of the 
excrementitious substances which have been eliminated. The patient 
should drink very freely of hot water with or without alcoholic stim- 
ulants, as it is most acceptable to the stomach. External heat should 
be used freely to the extremities. Filling the bowels full of hot water, 
not too hot, has been practised as far back as 1832 by Lizars. Tannic 
acid added to the hot water was found by Cantani to be the most 
effective. Hay em's formula for a saline solution to be injected into 
the cellular tissue of the buttock (instead of throwing it direct into the 
saphenous vein, as recommended by some authors) consists of one thou- 
sand parts of distilled water to five parts of sodium chloride and ten 
parts of sodium sulphate. The injection is slowly made by means of a 
'fountain syringe, to which the instrument for injecting the fluid is 
attached. A large quantity can then be taken and rapidly absorbed. 
Then the part should be deadened with ethyl chloride before passing 
the instrument into the tissue, thus causing no pain to the already suf- 
fering patient. The process can be repeated until the desired result is 
secured or the method proved to be useless. 

Professor Cantani suggests, as the most successful time for resort- 
ing to hypodermoclysis, the first indications of insufficiency of water in 
the body, such as discoloration of the skin, cramps, coldness, that is ro 
say in the beginning of the algia period. The formula for the fluid 
used by Cantani for hypodermoclysis is for an adult, as follows : — 

5: Pure sodium chloride 80 grams 

Sodium carbonate 6 grams 

Dissolve in 2 litres of boiled water. 

The quantity to be injected each time varies, according to circum- 
stances, from one to two and one-half litres. The temperature of the 



Cholera, or Cholera Asiatica. 57 9 

solution should be 38° Centigrade, unless that of the rectum be very 
low, in which case it has sometimes been raised to 43° Centigrade. 

The apparatus required is very simple. One of the best forms 
consists of an ordinary fountain syringe having a long elastic tube, to 
the distal end of which is attached a fine-pointed metallic canula, sup- 
plied with a stop-cock. The operation is as simple as the apparatus. 
The region preferred is either the mammary or the ileo-costal region. 
A fold of the skin is raised, and the canula, previously filled with fluid, 
is inserted quite a distance between the skin and the subjacent fascia. 
The fountain of the syringe is elevated until the fluid begins to flow by 
gravity. In fifteen to twenty minutes one to two litres can be thus 
injected. During the process the current should be interrupted at 
intervals by means of the cock. Upon withdrawal of the canula after 
completion of the operation, the tumor should be gently rubbed, when 
the fluid will very soon be absorbed. 

The warm bath also, in conjunction with hypodermoclysis, appears 
to exercise a powerful influence upon absorption. 

After hypodermoclysis, hypodermic injections of stimulants, of f en 
so urgently called for, especially during the stage of collapse or rigidity, 
become active, while they have before been inert. If after a first injec- 
tion the coldness and the wrinkling of the skin persist, and the secre- 
tion of urine is not reestablished, if, in a word, we are convinced that 
the tissues are not yet supplied with the water which they have lost, 
repeat the operation some hours later. 

"In the majority of cases, however, after the first hypodermoclysis, 
if the internal losses have not been such as to be incompatible with a. 
good reaction, the circulation is reestablished, the avenues open, bathed 
once more with their natural fluids, and sIioav an expression of con- 
sciousness. Little by little the lividity of the skin diminishes, and the 
voice becomes normal. In less than an hour, a person who was at the 
mouth of the grave is restored to life." 

In sirmmarizing the treatment Cantani says: "First period of 
cholera : Rest in bed, warm infusions with laudanum or chlorodyne and 
cognac, warm bottles to the feet, warm general baths, warm tannic 
enteroclysters — certain cure. 

"Second period, specific or rice-form diarrhea : Always warm baths, 
lemonade acidulated by chloro-hydric or tannic acid, with laudanum, 
spirituous liquors, warm tannic enteroclysters, lumps of ice swallowed 
- — cure almost certain. 

"Third period, vomiting, diarrhea always more profuse, cramps 
and coldness, commencing cyanosis : Hypodermoclysis and baths, alter- 
nated with tannic enteroclysis, hypodermic injection, revulsives exter- 
nally — very many cures." 

In the stage of typhoid reaction the skill, judgment, experience, 
and watchfulness of the physician are taxed to the utmost. It should 
always be borne in mind that we have to do with a fever of septic char- 
acter consequent upon extensive abrasion or destruction of the mucous 



580 Cholera, or Cholera Asiatica. 

surfaces of the intestinal canal, and complicated by serious involve- 
ment of the liver, of the kidneys, sometimes of the blood, and of the 
general nervous system; hence great care should be observed in the 
selection of the line of treatment to be followed. 

Prognosis. — The mortality of cholera infectiosa is known to be 
sometimes frightful. It is usually greater in the earlier course of the 
epidemic, and it is limited almost entirely to those who neglect to 
invoke the aid of the physician until the attack has become exceedingly 
grave. Send for the physician in the early stage, and the danger of 
a fatal issue is not so great. If in practise enteroclysis and hypo- 
dermoclysis meet the claims made for them, as above stated, the disease 
will be robbed of many of its terrors. 



CHAPTEK XLIV. 
MALAEIA. 

Definition. — By malaria is meant affections which are due to a 
specific poison, produced by the presence in the human body of a 
peculiar hsematozoon. These affections have been divided into various 
groups, which have been characterized by the type of fever that accom- 
panies them; in this way we have the intermittent, the remittent, and 
the continuous forms. It has been found that well-marked attacks of 
malaria exist without the production of fever, so that forms occur in 
which the symptoms may be of any one of these types, that is, inter- 
mittent, remittent, or continuous, without being characterized by an 
elevation of temperature. 

Etiology. — Malarial diseases are not contagious, and do not pass 
from one person to another; they are the outcome of a poison which 
is produced outside of the body. This poison results from a suitable 
soil, an abundant moisture, and a sufficient heat. These conditions are 
widespread; malarial districts are found throughout the world. Heat 
of climate, as a rule, increases the virulence of the poison in the infected 
districts, so that the most deadly malarial countries are tropical or 
subtropical. The character of the soil necessary for the production of 
malaria is not thoroughly understood. It is probable that there are 
organic or inorganic constituents of certain soils which inhabit the 
growth of the malarial organisms, and therefore render healthful a 
certain swamp in an infected district. The amount of moisture in a 
soil has immense influence ; if a tract is covered all the time with even 
a very shallow depth of water, it is almost innocuous ; if it is alternately 
exposed and covered with the changes of the tide, it may be very dan- 
gerous ; but the most deadly of all localities are those in which, without 
there being water upon the surface, the ground water reaches close to 
the top of an alluvial soil containing much organic matter. It was 
such a soil that in the famous Walcheren campaign in 1809 put twenty- 
seven thousand out of forty thousand English soldiers into the hos- 
pital. As a rule, great fresh-water lakes, and the deltas of rivers and 
the country around, are abundant producers of malaria. The dam- 
ming of rivers and the draining of marshes are powerful factors in 
increasing the production of malaria. Cultivation of the soil has been 
observed to lessen in some way its productive power, so far as malaria 
is concerned. It is noticed that in the production of malaria changes 
take place which are not easily accounted for. In the New England 
and the Middle United States it is clear that there has been a great 

(581) 



582 Malaria. 

decrease of malaria; whereas it is asserted that about the ports of the 
Gulf states the disease is, on the whole, increasing. Can this be due to 
the importation of fresh, extremely virile germs from the tropical 
islands and mainland? It is affirmed that malaria has disappeared 
from Lake Ontario ; and in the northwestern states it is almost unknown. 

Age has little or no influence upon the susceptibility to malarial 
poison, and instead of an attack affording protection against the dis- 
ease, it renders the subject much more liable. Nor is there, so far 
as is known, any heredity in susceptibility ; the white races at least do 
not become accustomed to the disease, but in fact degenerate in the face 
of .a persistent, overwhelming malarial poison. On the other hand, it 
is said the negro races and, to a less degree, the Arabs also, enjoy 
almost an immunity. The late summer and the early fall are the 
seasons of greatest danger. 

Malaria is more a disease of the country than of the town. In 
thickly-populated cities the conditions are not favorable for the develop- 
ment of the germ ; but it is not true that complete protection is afforded 
even in the most thickly-populated city. Heavy fogs in the country 
and the moist air of night favor the rising from the ground and 
the dispersion of the malarial poison. Moreover, owing probably to 
mechanical reasons, high elevation above the earth affords protection, 
and the obstruction of a high wall or a dense wood may be sufficient to 
alter distinctly the malarial relations of a certain place. High winds 
may carry the germs to a considerable distance. 

In 1879 M. Laveran, a French army surgeon, announced the dis- 
covery of a hsematozoon, the germ of malaria. In 1883 Marchiafava 
and Celli published their researches, which eventually led them to 
accept, as the cause for malaria, the so-called plasmodium malaria. 
"This plasmodium" can be produced by a variety of poisons acting upon 
the red blood-corpuscles of typhus and scarlatina and in progressive 
anaemia. It is said, however, that these researches still require verifi- 
cation. (Rosenstein.) 

Pathology. — This poison may act in two ways: first, generally; 
second, locally. Its general effect may be summed up as that of almost 
any foreign substance introduced into the circulation, — the production 
of chills, fever, etc. This series of symptoms is preceded by a period 
of incubation, which, according to different authorities, may vary from 
a few hours to a few years ; but the average number of cases is repre- 
sented by two weeks. The local effects are due to an especial develop- 
ment of virus at given places, as the spleen, the liver, the brain, the 
blood-vessels, etc. The effect of the poison upon the blood is a destruc- 
tion of red corpuscles, an increase in pigment (directly depending upon 
it), and a diminution in albumen. The effect upon organs or tissues 
in which the poison or its results are lodged is the production of irri- 
tative changes leading to hyperplasia or hypertrophy. With the above 
data in view, the lesions are readily understood. Of all the organs in 
the body, the spleen suffers earliest and most. During an attack the 



Malaria. 583 

spleen is enlarged; when the fever disappears, as a rule the spleen 
returns to its normal size ; it enlarges again upon a return of the fever, 
and finally it becomes more or less permanently enlarged. This enlarge- 
ment is due to hypertrophy and the deposit of pigment. Frequently 
there is inflammation in the capsule, sometimes peri-splenitis. The 
liver also becomes enlarged, like the spleen. This enlargement is clue 
to a similar process, but is characterized by an enormous deposit of 
pigment. 

The disintegration of red blood-corpuscles gives rise to an almost 
endless number of changes. The lymphatic spaces around the vessels 
are filled with pigment, so that the contours of the vessels are empha- 
sized, as in the brain. On account of nutritive changes in the blood, 
the vessel walls frequently become weakened, and then hemorrhages 
follow, under the skin, into the cavities of the body, or with the secre- 
tions. Digestive disturbances are likewise noted. 

Local disturbances, of great importance to the pediatrician, are 
quite common in the bronchial tubes, so that it may happen that the 
patient survives his attack of malaria, but succumbs to catarrhal pneu- 
monia, the sequel to malarial bronchitis. In the pernicious forms the 
lesions are splenic enlargement, changes in the brain, hemorrhagic 
infarctions, etc. It is seen that there is hardly a tissue or organ in the 
body which may not be attacked by this malarial poison. 

Symptomatology . — The paroxysms of an intermittent fever may 
come on suddenly, or they may be preceded by malaria, anorexia, or 
other general prodromes. The attack presents itself in three different 
forms, namely : first, the chill ; second, the fever ; third, the sweating. 
In the first stage there is a coldness in the back, which soon radiates 
over the whole body, and is accompanied with horripilation, which the 
writer has seen become so violent that the teeth chattered, and the body 
trembled sufficiently to shake the bed on which the patient lay. The 
skin is pale, cold, and has a goose-flesh appearance. Vertigo, cephal- 
algia (headache), ringing in the ears, trouble of vision, dilated pupils, 
vomiting, abundant urination, and frequent small pulse are common 
phenomena. The bodily temperature begins to rise at the very onset 
of the attack, so that before the chill is over 104° or 105° Fahrenheit 
may be reached and the surface be extremely hot. The eyes are bril- 
liant, face congested, pulse strong (perhaps dicrotic) ; there is violent 
headache, and often great and varied nervous disturbances, such as 
mental confusion, unrest, and even delirium. As a rule, in from three 
to four hours, but in some cases eight to ten hours, the dry skin breaks 
out into a profuse perspiration, which is followed by a rapid fall of 
the temperature to 98° Fahrenheit, and usually in from two to four 
or more hours the subject has apparently recovered his normal condi- 
tion. In some cases the spleen is somewhat enlarged and tender dur- 
ing the fever stage, which abates after or during the sweating stage. 

The so-called quotidian type presents itself daily. The tertian 



584 Malaria. 

type recurs every other day; the quartan type, every third or every 
fourth day. 

There are also double forms, — double quartan, for instance, in 
which there is an attack on two successive days and one day without 
an attack, or double quotidian or tertian. In double quotidian we have 
two chills daily, one in the morning, one in the evening; in double 
tertian, one chill daily, the time of the chill alternating every other 
day. In children the quotidian form is the most common. The attack 
most usually comes on between ten o'clock in the morning and one in 
the afternoon. It will be understood that this is the rule in the great 
majority of cases; there is no time in twenty-four hours when a chill 
may not come on, but for practical purposes it is best to assume that 
an attack will follow the rule, and not the exception. 

Authors differ very much as to this rule, 1 and possibly the time 
when the infection has taken place, or the method of infection may have 
something to do with the different observations that have been made. 
If anything has been established, it is the liability to relapse. (Forch- 
heimer, M. D.) The time of relapse has been the subject of very much 
discussion. Children are more liable to relapses than adults, and, 
depending upon the type of the attack, relapses are most common on 
the seventh, the fourteenth, and the twenty-first days. This is true 
especially of the quotidian and tertian forms. The quartan form has 
a tendency to relapse on the eighth day, although changes of type 
from quartan to tertian or quotidian are by no means uncommon. 

There are two forms of the intermittent type, the pernicious and 
the mild form. In the pernicious form, which is not rare in infancy 
and childhood, the patient is taken sick suddenly; the child has been 
perfectly well, and suddenly may go into convulsions. Before this, 
the parents may have observed that the child is restless, that it has 
assumed a bluish-pale color, perhaps that it has vomited, or has had 
one or two loose passages. Upon examination, it will be seen that 
the child is well nourished, with a temperature very high, up to 104 
degrees to 108 degrees Fahrenheit, in the rectum. Perhaps you 
will find nothing but an enlarged spleen, and this is not constant 
by any means. The convulsions may continue, the patient being 
soporose or comatose; the pupils are contracted, or one is dilated and 
the other is contracted ; lividity occurs over the whole body ; the extrem- 
ities get cold; and this first attack may end fatally. As the convul- 
sions gradually diminish in intensity and number, the extremities grow 
warmer, the bluish color disappears, the temperature begins to fall, 
consciousness returns between the convulsions, and towards evening the 
child seems comparatively well. The same kind of attack may come 
again the next day, either weaker or stronger, usually the latter, and 
may then end the patient's life. Or the attack may come on simply as an 
attack of coma in an otherwise healthy child, from which condition the 



1 Virchow and Bohn, loc cit. 



Malaria. 585 

patient never rallies, lying for from one to tnree or four days, and then 
dying from asthenia, oedema of the brain, or other complication. The 
convulsive form may leave the child in this comatose condition and 
the termination be in the same way as in the case where coma sets in 
immediately. Rarely do these pernicious forms terminate in the 
development of the benign intermittent, and the prognosis is almost 
invariably a fatal one. It is difficult to make a diagnosis with certainty 
in the absence of any positive symptoms. The importance of search- 
ing for the plasmodium malariae in these forms can not be too strongly 
dwelt upon. 

In the benign forms of chills and fever we must carefully dis- 
criminate almost entirely between the separate conditions, the one 
occurring in infants and the other occurring in older children. In 
infants we rarely have a complete attack, i. e., one made up of a chill, 
fever, and sweat ; it is either one of these alone or most commonly two 
together. The one thing in the infant which is most commonly missing 
is the chill ; the one which is always present is the fever. Bohn and 
others state that very young infants do have chills. In malarial dis- 
tricts in the country in the southern states, physicians see young infants 
shake with a true chill produced by malaria. The child begins to 
yawn or stretch itself as if it were very tired; the face changes in 
expression and color, and has a pale, pinched look. The nose espe- 
cially is pinched and cold ; the eyes sink in, and have bluish lines about 
them; the lips are blue, and the little one is very tired-looking. The 
fingers and toe-nails become cyanotic, and if this occurs after a meal, 
the patient vomits or feels nauseated. All this is a mild manifesta- 
tion of a chill. The next thing we see the involvement of the nervous 
system, twitching of the eyelids or of the extremities, associated with 
what has been described above, which causes the physician to fear the 
developing of convulsions. A great many infants have convulsions at 
the onset of any acute affection, and frequently we find that in inter- 
mittents the chill is represented by convulsions, which are followed by 
the next stage. The convulsions naturally cause very great anxiety, 
because in and of themselves they are very dangerous, and for this 
reason at first the physician does not know but that he is dealing with 
something very much more serious than an ordinary attack of chills 
and fever. After the convulsions have ceased — and they do this, as a 
rule, after a short time, not exceeding a few hours, the first one being 
usually the severest — then comes the period of fever. During the 
chill period the temperature has gone rapidly up to 103° to 108° 
Fahrenheit (rectal), and remains there throughout the whole period 
of fever, sinking very gradually towards the end of this period, and 
after from three to five hours reaching normal or subnormal. With 
this fever there is more or less restlessness, the patient is very much 
flushed, feels very dry, is fretful and cries, and, as in the previous stage, 
may have gastro-intestinal disturbances. The sweat that follows is pro- 
fuse when it does occur ; but although the little patient seems exhausted, 



586 Malaria. 

the appetite returns, and the child seems perfectly well. However, 
after one or two attacks — and this is true of older children as well — 
the cachexia begins to manifest itself. The patients lose their natural 
color; they are pale, sometimes jaundiced, listless, languid, having lost 
their appetite, and do not take much interest in their surroundings, as 
has been their custom. With this the spleen becomes enlarged. It is 
rare not to find the spleen enlarged in the malaria of children, accord- 
ing to the authors upon this subject, — Emmet Holt, Schneidler, also, in 
the "Archives of Pediatrics." The intermittents of older children do 
not differ materially from those of adults. They. are able to describe 
thpir sensations, and they react like adults. 

MANIFESTATIONS IN THE NERVOUS SYSTEM. 

Not a nerve in the whole body seems to be exempt from affection 
by malaria. In the cerebro-spinal system of nerves the symptoms mani- 
fest themselves as neuralgias. The fifth pair of nerves is the one most 
commonly affected. There is supra or infra-orbital neuralgia, frontal 
or occipital headache, pain in the teeth, and sometimes alongside of the 
nose. Neuralgias of the sciatic nerve, the intercoscal nerves, and the 
nerves of the stomach are by no means uncommon. Another form is 
called wry-neck, or torticollis intermittents. There are three states of 
this condition, the first being purely torticollis, the second absolutely 
intermittent with high fever or continuous, and the third with brain 
or cord complications, presenting the picture of a cerebro-spinal menin- 
gitis. The patient is attacked at a certain time of day with a pain 
in the back of the head and along the upper part of the spinal column. 
With this there is torticollis. The attack lasts for from two to five or 
six hours, and then the patient feels perfectly well. This is the mildest 
form. The next day the attack repeats itself, and resembles in every 
respect an ordinary intermittent. The forms above described may run 
into one another, and, although at first very amenable to treatment, may 
develop so as to be beyond control. 

There are also disturbances of the vasomotor nerves which cause 
peculiar symptoms. Among these special reference is made to inter- 
mittent swellings, more particularly about the joints, and sometimes 
within them. They give rise at times to great pain; at other times 
they are painless. 

AFFECTIONS OF THE RESPIRATORY ORGANS. 

The whole of the respiratory tract, from the mucous membrane of 
the nose to the alveoli of the lung, may suffer from malarial poisoning. 
Sometimes we observe true intermittent attacks of coryza, or, combined 
with this, enlargement of the tonsils. One alone or all combined may 
exist. The most common form of catarrhal trouble due to malaria is 
a subacute or chronic condition extending over the whole mucous mem- 
brane of the pharynx, nose, and eyes. We also have attacks of epis- 



Malaria. 587 

taxis. These may become dangerous to life on account of the great 
loss of blood during the attack, or on account of repeated attacks. It 
is advisable to examine the nose in these cases; for frequently it will 
be found that there is a peculiar ulceration upon the septum, which 
should be treated. Attacks of bronchitis more or less diffuse, as the 
only symptoms of malarial infection, also occur. If they are in the 
capillary bronchi, they may become very dangerous. As it is, they 
must always be carefully watched, and the patient be given the full 
benefit of liberal treatment. 

MANIFESTATIONS IN THE ALIMENTARY TRACT. 

Very few intermittent cases occur without some symptoms being 
produced in the alimentary canal ; but complications have been treated 
of before, and we now refer to those forms in which the symptoms on 
the part of the alimentary canal are the principal manifestations. The 
stomach, the small intestine, and the large intestine, either alone or 
together, may be the seat of disturbance, which alone goes to make up 
an attack. The stomach symptoms are dyspepsia, either constant or 
intermittent. These attacks are entirely independent of any food that 
is taken. The child may be fed in the most correct manner, and yet 
the attacks continue. That form which manifests itself in attacks of 
vomiting is very peculiar. The child may be in perfect health, play- 
ing about, happy and jolly, when it is suddenly taken with the ordinary 
symptoms of nausea. Then vomiting conies on. After four or five 
hours the child, although looking dragged out, seems perfectly well; 
its appetite returns, and it remains perfectly well until the next attack 
comes on. With this there may be a slight elevation of temperature 
(101° to 102° Fahrenheit) ; the spleen is usually enlarged, as it is in 
every form of malaria in children ; and when these attacks continue, the 
little patient suffers very much so far as general health is concerned. 
All the symptoms coming from the alimentary tract in malaria are most 
easily controlled by quinine. 

On the part of the intestines we have diarrhea. This is of two 
kinds, — the large and watery stools, and the small, slimy, bloody ones. 
The attack consists simply in having these stools. There is no pain, as 
a rule, except in the large intestinal variety. The patient does not 
suffer inconvenience; and after the attack is over, he feels perfectly 
well. The diagnosis of these gastro-intestinal forms' is readily made : 
the fact alone that all the remedies which usually control diarrhea, 
combined with proper diet, fail, is sufficient to cause the practitioner 
to suspect that he is dealing with malaria. The prognosis is favorable 
in all forms. It must not be forgotten, however, that there may be 
deeper lesions present in the intestines, which may lead to very unpleas- 
ant complications, — tuberculosis, peritonitis, etc. 



588 Malaria. 

MANIFESTATIONS IN THE CIRCULATORY SYSTEM. 

It seems from all observations that attacks on the part of the heart 
are more rarely noticed. They must be rare or more cases would be 
recorded in the literature of malaria. An irregular distribution of 
blood is noticed in that form in which vertigo, with congestion of the 
face, is the only symptom. This dizziness is the only thing the per- 
son complains of, but it returns with the same regularity which char- 
acterizes all these forms. Another form is attacks of palpitation of 
the heart, which is also easily controlled by quinine. 

Z MANIFESTATIONS IN THE URINARY ORGANS. 

Special manifestations of attacks in the urine are hematuria or 
albuminuria or glycosuria. In reference to the first we notice the 
appearance of blood in the otherwise normal urine. This blood is dis- 
charged with or without pain, according as it coagulates in small or 
large masses, is usually of a bright red color, and its loss does not affect 
the patient very much. The urine always contains albumen in variable 
quantity. The cases, as a rule, are of slow recovery, but the prognosis 
is not bad. Quinine does not act as a specific; in other words, these 
cases are not affected by the use of quinine, but removal to a non- 
malarial climate gives relief in a very short time. 

MANIFESTATIONS IN THE SKIN. 

No proof has been offered that there exists any relation between 
skin disease and these affections of malaria. 

Troubles in the mouth are common in chronic malaria, from the 
simple stomatitis to cancrum oris, the latter sometimes ending the life 
of a cachectic subject. 

Diagnosis. — The diagnosis of an ordinary malarial fever is easy, 
but in irregular malaria it may be misleading. If paroxysmal dis- 
turbances of any character recur at not very long intervals with show 
of regularity, malarial disease should be suspected, and an examination 
of the blood be made, or the effect of quinine be determined. If suffi- 
cient doses of quinine fail to influence the paroxysmal disturbances, the 
probabilities are altogether against such disturbances being of malarial 
origin. There is a continued type of fever which prevails in the south- 
ern states, and it is affirmed by various practitioners that it can not be 
arrested by quinine. 

The most common forms of paroxysmal fevers simulating malaria 
are those of septicaemia and hepatic disease. If there is no organism 
detectable and no response to quinine, the case is said not to be con- 
sidered malarial. In looking for malarial organism the practitioner 
can obtain most satisfactory results by the direct examination of fresh 
blood. A thin cover-glass freshly cleaned with nitric acid, then with 
alcohol, and finally with ether, receives a very small drop of blood from 



Malaria. 589 

the end of the finger or the lobule of the ear, and is placed upon a thor- 
oughly cleaned glass slide. The blood will spread into a thin layer by 
the weight of the cover-glass^ and should at once be examined with the 
aid of an oil-inmiersion lens. The parasites may be seen with a dry 
lens of high power, but best results are obtained only with the immer- 
sion lens. (Wood.) 

Prognosis. — Malarial fever is always curable; if at once recog- 
nized and properly treated, it never ends in death. In tropical coun- 
tries malarial diseases, especially if reenforced by continued exposure 
to the cause, may end fatally. 

Prophylaxis. — There is no absolute protection from malaria, but 
much can be done by those who must expose themselves by obeying the 
simple rules : First, avoid going out in the early morning or during the 
evening or night, especially when the weather is in any degree foggy; 
second, sleep in the second or third story of the house ; third, take from 
five to ten grains of quinine either directly after breakfast or on going 
to bed at night. This applies to people who have malaria, and who 
live in a malarial district. 

Treatment. — The ordinary paroxysm of intermittent fever requires 
no treatment, other than that, upon recognition, the patient should take 
a full dose of calomel and podophyllin, and in the morning an adult 
may take from fifteen to twenty-five grains of quinine, so administered 
that the first dose shall be taken from eight to ten and the last dose 
from four to five hours before the expected recurrence of the paroxysms. 
The exact amount of quinine given should depend upon the known 
obstinacy of the malaria of the district. To the adult in the northern 
states, twenty grains are given ; for the south, thirty grains are recom- 
mended. The second day the quinine is repeated in smaller doses, 
according to the effects of the first administration. The paroxysm hav- 
ing thus been broken, the patient should be put upon Fowler's solution, 
from three to six drops after meals, and no more quinine given until 
the seventh day, at which time the malarial paroxysm has a pronounced 
tendency to recur ; to prevent this recurrence, from fifteen to twenty 
grains of the alkaloid should be administered every seventh day for 
from four to six weeks. The quinine must be given in solution or in 
capsules, or in fresh pills of the bisulphate. Old sugar-coated pills are 
not to be trusted ; they are not prompt. 

When the malarial paroxysm takes on an irregular form, brouhague, 
for example, larger doses of quinine are required to put it aside, so that 
from twenty-five to thirty-five grains should be given in the intervals, 
and repeated in ascending doses until complete control is obtained. 

The treatment of a pernicious malarial paroxysm is a matter of 
the greatest importance. Amyl nitrate will at once put an end to the 
chill in an ordinary malarial paroxysm without in any way interfer- 
ing with the after-development of the fever and sweat. It is thought 
probable that the drug will prove of service in the algid form of per- 
nicious malaria in bringing about reaction. If the central temperature 



590 Malaria, 

during a pernicious chill is low, the hot bath should be used. When 
there is a distinct hyperpyrexia (a very high fever), cold affusions may 
be used aboiit the head, neck, and arms ; while at the same time external 
heat and mild sinapisms are used freely on the extremities. If heart 
failure is threatened, a free use must be made of digitalis, hypoder- 
mically, with strychnine and cocaine. No time must be lost in produc- 
ing a profound cinchonism, in the hope that by destroying the forming 
crop of parasites the paroxysms will be diminished. If the stomach 
can not be employed, a well-assidulated (tartaric acid) rectal injection 
of thirty grains of quinine bisulphite may be administered, while ten to 
twenty grains of the bisulphite are given hypodermically. Two hours 
later, if relief has not come, the rectal injection should be repeated. 
At least seventy-five grains of quinine should be given within eighteen 
hours after the first coming on of the paroxysm, and cinchonism should 
be steadily maintained for a week, to be folloAved by the free use of 
Fowler's solution, with iron and other tonics and the weekly doses of 
quinine. (Wood.) 

The successful treatment of chronic malaria is often one of great 
difficulty. Experience has shown that quinine has much more influ- 
ence in these cases if given along with drugs which act upon the emunc- 
tories ; in some cases potassium bitartrate does good, and a bitter purga- 
tive, such as small doses of aloes given daily for a length of time in 
such doses as will produce soft stools, is often of the utmost service 
where there are heptic congestion and enlargement. Mercurials, nitro- 
hydrochloric acid, and ammonium chloride may be necessary before 
success in chronic cases can be reached. In obstinate cases arsenical 
preparations are valuable (Fowler's solution). Iron and simple bit- 
ters may be freely administered — all the stomach will bear. Removal 
from malarial districts is often necessary. In bad cases of malarial 
'anemia it may be essential to put the patient to bed, and even some- 
times to enforce a modified rest-cure. When the spleen is chronically 
enlarged, iodine ointment may be used externally over the organ, while 
solid extract of ergot is given in full doses, from twenty to thirty grains 
a day, in capsules. 

The Treatment of Malaria in Children. — The administration of 
quinine to children is no easy matter, where quinine must be given in 
large doses to break up some forms of malaria. A great many chil- 
dren can not bear it upon their stomachs. The normal dose for inter- 
mittents that we use is as follows: For a child below six months of 
age, one to two grains ; from six months to one year, two to two and a 
half grains ; from one year to two years, two and a half to three grains ; 
from two years to ^.ve years, three to five grains ; and from five to 
twelve years, Hve to eight or ten grains, depending ugon the size, the 
strength of the patient, and the return of the affection. Quinine can 
be administered by one or all of the methods used in giving drugs, — 
by the mouth, the rectum, the skin. There is no known method by 
which the bitter taste of quinine can be effectually disguised that can 



Malaria. 591 

be made applicable to the administration of sufficiently large doses. 
Liquorice is the best vehicle, the syrupus liquoritise. We need it most 
in children from three to five years old, just where it can not be used 
on account of the large quantity of the liquorice required. When the 
child can swallow pills, this mode is preferred. In giving quinine by 
the rectum — in which way it works just as promptly as per mouth, 
but requires a double dose — two ways are open to us, by injections 
and by suppository. It must be confessed that the latter method is 
much more satisfactory than by the injection. For an injection, sus- 
pend the quinine in sweet cream or any bland fluid, as flaxseed tea, or 
an emulsion of sweet-oil would undoubtedly do as well. The sup- 
positories can not contain over five grains each ; this size would be suf- 
ficient for infants, but two or more would be needed for larger chil- 
dren. The quinine should be mixed in cocoanut butter made into sup- 
positories. Great care should be taken in mixing the quinine properly, 
as the quinine has the power of crystallizing on the outer surfaces, 
thus causing them to irritate the intestinal mucous membrane. The 
hypodermic injection is necessary in cases where all the other methods 
fail, or where it is necessary to get quinine into the system as quickly 
as possible, as in cases of the pernicious form. The great objection to 
its use in this way is that it produces abscesses. However, it is better 
for the patient to have an abscess produced in this way than to lose his 
life, although if proper antiseptic precautions are used, the danger of 
an abscess being thus formed is by no means certain. l$o substitute 
has been found for quinine ; but the remedy next in importance is 
arsenic. This is most applicable to the chronic forms, and is to be 
administered between various doses of quinine, which are given to pre- 
vent relapses every seven, fourteen, or twenty-one days ; arsenic must 
be given in full doses, although it is not necessary to produce its toxic 
effects. It can be given for months at a time, and should be given 
until we have reasonable assurance that the spleen has returned to its 
natural size. 

In the remittent and continuous forms, quinine does not have any 
other effect than it would have in any other fever, i. e., that of an anti- 
pyretic. The treatment of these forms is simply symptomatic. Those 
who have dealt most with the continuous forms of remittent fever, prefer 
to begin the treatment with a mercurial, following this up with quinine 
in small but frequently-repeated doses. Especially in the continuous 
forms, the patient should be kept in bed, put upon diet, and watched 
very closely until the physician is positive that he is not dealing with 
a mild form of typhoid. 

For the treatment of the chronic forms and the cachexia, the child 
should be removed to a non-malarial region. If the removal is only 
from one district of the city to another, provided there be no malaria 
in the quarter to which the patient is taken, the result will be good; 
mountain resorts are to be preferred. Besides quinine and arsenic, 
all the tonics have been used ; especially iron with quinine produces 



592 Malaria. 

very good results. For the affections of the nervous system accom- 
panying malaria, strychnine in very small doses is of value. The 
enlargement of the spleen will be found to yield to faradization. This 
method of treatment has seemed to me frequently to give good results, 
although recent reports do not appear to warrant its use, because of 
its being unserviceable in some authors' hands. 

In all the various neuralgic forms in children, antipyrine fre- 
quently acts like a charm, not as a curative, but as a palliative. Acet- 
anilide is recommended to have special control over the neuralgia of the 
fifth pair of nerves due to malaria. The treatment has to be modified 
to suit each individual. 

Lemon- juice, given in doses of two drachms to a half ounce, twice 
or three times daily, in some cases certainly produces good results. In 
others the results have been negative. 



CHAPTER XLV. 
YELLOW FEVER. 

Definition. — Yellow fever is an acute febrile disease, characterized 
by fever, lasting from one to four days, followed by an intermission, 
with, in severe cases, a secondary exacerbation, a steady fall of the 
pulse, which commences during the period of fever, jaundice, a tend- 
ency to stasis of circulation and to hemorrhage, and parenchymatous 
inflammation of the liver, kidneys, and stomach. 

Etiology. — The question of the contagiousness of yellow fever has 
been investigated and discussed most extensively, so that at the present 
time it seems established that the disease is incapable of passage directly 
from man to man, but that the poison, whatever its nature may be, 
passes from the sick into some favorable locality, where it develops 
the activity which enables it to infect another person. For the growth 
and development of the poison outside of the body, certain conditions 
are necessary. These conditions probably are, first, a steady, well- 
maintained temperature ; second, the presence of filth. 

It has been a widespread belief that this filth must have at least 
some animal matter in it, and that excrement it ions material is especially 
fit for its development. It would seem that the most favorable condi- 
tions are the existence of high temperature and the presence of such 
mixed masses of vegetable and animal filth as prevail about seaports. 
The effect of cleanliness was strongly illustrated in the banishment of 
yellow fever from New Orleans by the rigid military sanitation enforced 
by General B. F. Butler during the Civil War. 

The usual history of an epidemic is a dirty town, a single imported 
case, and a resulting outbreak of the disease. In an instance reported 
by Guiteras, a man moving from an infectious district had fever in his 
own house, which was kept clean, with no spread of the disease ; during 
convalescence he went to another village and lived in a dirty room, 
which room became a source of infection for a number of cases. In 
another case the clothing of a sailor dying from* the disease was packed 
in his chest and sent to his wife in New York ; two persons were pres- 
ent at the opening of the chest, and both were infected. 

We have no knowledge of the nature of the germ ; it is believed, 
however, to be an animal organism. 

Symptomatology and History. — The period of incubation varies 
from a few hours to fourteen days, although it is very rare for the dis- 
ease to develop after the ninth day. The invasion, which occurs more 
frequently at night, is abrupt, with repeated chills, excruciating pains 

(593) 



594 Yellow Fever. 

in the back, head, and limbs, and an immediate rise of temperature. 
Vomiting is very common, and in some cases an exanthematous rash 
appears, especially in the sacral regions. There is usually an evening 
exacerbation of temperature on the first day ; but on the second or third 
day the characteristic fall of temperature begins and continues, though 
sometimes interrupted by evening exacerbations until it reaches the 
normal from the second to the fourth day. 

During the whole period of the fever there are great anxiety, 
restlessness, intense suffering, and not rarely delirium, varying in 
degree from slight mental confusion to wild mania ; in some cases there 
is^ stupor. The pain disappears when the fever subsides, the mind 
becomes clear, and not infrequently all anxiety is lost. There remains 
an increasing epigastric tenderness, with continuing and increasing 
slowness of the pulse, perchance a little heaviness ; soon jaundice 
appears, first generally in the forehead and conjunctiva, and rapidly 
increases until the whole surface is dark yellow, and the deep brown 
urine is heavily loaded with biliary constituents. 

The period of remission may end in convalescence, but commonly 
there is developed a second paroxysm of fever, with well-marked diurnal 
remissions and sometimes hyperpyrexia. Even during the remission 
the failure of strength is usually marked ; but in the fever of reaction,, 
as it is called, the adynamic system becomes more pronounced. Death 
may occur during the secondary fever, or, after a prolonged, irregular 
course, by gradual abatement of symptoms, the patient passes into con- 
valescence. In severe cases the jaundice deepens until the whole sur- 
face is uniformly bronzed. The vomiting recurs, and becomes uncon- 
trollable, while brownish or blackish flakes appear in the matter ejected, 
and increase in number until the whole fluid is black and opaque. The 
capillary circulation becomes so nearly stagnant that the dependent and 
extreme portions of the body, — fingers, toes, scrotum, back, etc., — are 
deep purplish. The urine lessens in quantity and may be completely 
suppressed. Hemorrhages occur from the various mucous membranes, 
even from the gums. Petechias vibices, hematuria, bloody stools, and 
an intense apathy mark the complete degradation of the blood and 
the failure of the vital power, which deepens until a quiet death results. 

While the course of yellow fever is for the most part fairly uni- 
form and consistent, the cases vary in intensity from the mildest to 
the most severe type. (Fitz.) 

According to Guiteras, in young children yellow fever may be a 
very trivial disease, and even when severe is so lacking in character- 
istic symptoms that it is commonly diagnosed as an ephemeral or a 
thermic fever, or as a malarial attack. 

The black vomit consists of gastric mucus with altered blood- 
corpuscles, epithelial cells, bits of food, various fungi, and black amor- 
phous granules, evidently the last result of blood disintegration. The 
amount of albumen in the urine is usually directly proportionate to the 
severity of the attack, but it is possible for a case to go on till death 



Yellow Fever. 595 

with an abundant secretion of non-albivminous urine. During con- 
valescence, paratitis, abscesses, diarrhea, and other local disorders may 
be very troublesome. 

Diagnosis from the History of the Disease. — Guiteras, M. D., 
states : "I do not know of any disease with which an ordinary case of 
yellow T fever can be confounded if subjected to observation for two or 
three days. Yellow fever differs in every particular from the hemor- 
rhagic, the hemoglobinuric, and the remittent malarial manifestation. 

"In warm countries the question of diagnosis is complicated by 
a remarkable liability of children to fevers because they arise from an 
excessive demand made upon any of the important functions of the 
body. The function of heat inhibition must be overtaxed in the long 
summers of the tropics. Short cases of thermic fever will be readily 
confounded with yellow fever. As a means of diagnosis I can only 
insist upon the three cardinal points mentioned in the symptomatology, 
namely, the relation of temperature and pulse, the facies, and the albu- 
minuria." 

Prognosis. — Yellow fever is much milder in children than in 
adults. Among the unfavorable symptoms we should notice an 
extraordinary rise of the temperature during the fastigium, especially 
about the time lysis should commence, or when the temperature has 
already started on the line of descent. If the pulse rises rapidly at the 
same time, and the temperature reaches a maximum above that of the 
initial stage, the prognosis is almost necessarily fatal. A slow pulse, 
if it steadily loses in volume and resistance, is a grave sign, even though 
the temperature may be following a favorable course. Great agitation 
and increasing frequency of the respiration are also of very serious 
import. The suppression of the urine is a grave symptom, though it 
is more easily overcome in children than in adults. It is the rapid 
increase of the albumin in the second or third day that constitutes the 
most alarming symptom. A prolongation of the case beyond the sixth 
day may be taken as a favorable sign, though the patient may present 
very alarming symptoms. These are the typhoidal cases, of which the 
patient generally recovers after a prolonged struggle. 

Treatment. — Guiteras, M. D., states : "If cases are taken in hand 
early, no danger need be apprehended. One is led almost to believe 
that there must be some great specific which, promptly administered, 
is sure to exert a decidedly favorable action upon the course of the 
disease. 

"In the treatment of children it will be found that the following 
measures may be considered as safe for the relief of more or less dan- 
gerous symptoms. If the bowels are inactive, cream of tartar should 
be given. This is preferred by some, to counteract the acidity of the 
stomach. In older cases, who can take capsules I [Guiteras] often 
use the compound jalap powder in little laxative doses. If they are 
easily swallowed, these capsules are almost always retained. They 
appear to arrest vomiting, and I have continued to administer them at 



596 Yellow Fever. 

intervals, in some cases to the exclusion of other treatment — only in 
such doses, however, as will keep up a moderate activity of the intes- 
tinal secretions without griping. 

"If the stomach is very irritable, and the food is not retained, 
calomel should be given in preference to all other laxatives, and in 
minute and frequently-repeated doses. The admixture of lime-water 
with the milk, or the administration of small doses of carbolic acid 
with bicarbonate of sodium, or the use of ice, will often prove a good 
substitute for the calomel. Cold applications to the head may or may 
not be soothing ; a sinapism to the back of the neck will be found bene- 
ficial. Antipyrine and Dover's powders have given decided relief. 
Either of them may be recommended during the f astigium of the fever 
in ordinary cases. In grave cases, acetate of ammonium may be given 
with the tincture of digitalis, to keep up the activity of the circulation. 
The treatment of the suppression of the urine is often a hopeless task. 
The tincture of digitalis, as recommended above, will fill this indica- 
tion, if there is any possibility of filling it. In the more protracted 
cases, the use of stmulants and the tincture of the chloride of iron may 
overcome the difficulty. If the complication continues, I would advise 
calomel as the most certain diuretic to be used. I have seldom employed 
it in the case of children, because the suppression of urine does not 
often arise as a pressing indication for treatment, but in the adult the 
effect of calomel has been very remarkable. In adult cases I have given 
two or three grains every four hours, in capsule, either alone or in com- 
bination with small doses of compound jalap powder. The urinary 
secretion is started often before the third dose is administered. I used 
calomel as a diuretic in yellow fever for the first time in the epidemic 
of 1887. On the recommendation of Dr. Sternberg, the bichloride has 
been used, with the result of destroying pathogenic microbes in the 
intestinal contents. There is no proof that the theory has been made 
good by the experiment. But I am informed by those who used the 
bichloride that it certainly had the effect of increasing the secretion 
of urine and diminishing the amount of albumin. I have abandoned 
the use of the cold bath in the febrile diseases of children. Children 
under the age of seven years are very apt to show evidences of blood 
stasis in the c§ld bath before the internal temperature has been mate- 
rially reduced. 

"As soon as the black atrise begin to show themselves in the vom- 
ited matters, or even before, if the lysis is usually slow and the asthenia 
marked, we should prescribe the tincture of the chloride of iron in doses 
of five or ten drops every two or three hours. This treatment is often 
followed by an arrest of the hemorrhage and diminution of the vom- 
iting. In these cases good brandy should be diluted with milk, water f 
or carbonic-acid water. In many cases iced champagne is very well 
borne by the stomach. Special attention should be given to the chang- 
ing of the clothing and sponging of the body with diluted chlorine 
water, tepid or cool, as the condition of the patient may require. In 



Yellow Fever. 597 

some cases during this stage the jaundice may acquire unusual promi- 
nence, and a slight enlargement of the liver will be noticed. I recom- 
mended then that the chloride of iron be replaced by chlorate of 
potassium. 

"Upon the judicious use of iron, alcohol, and chlorate of potash, 
with nutritious diet, depend, in my opinion, the few triumphs that 
therapeutics may boast of. 

"The mortality of yellow fever is considerably reduced when the 
patients are treated in tents. 

"The frequent administration of food in small quantities during 
the lysis is probably of great importance, and the preference should be 
given to milk. We may substitute for it, at times, strong meat broths, 
especially when the time allowed for resting has brought together the 
hours for feeding and the administration of the iron. Soft-boiled eggs 
are tolerated even before convalescence is well established. Alcoholic 
preparations containing extract of beef may be used with advantage 
in protracted cases. 

"The use of cool acidulated drinks is very generally recommended, 
especially in the early stages. It is stated that if lemonade be boiled 
and subsequently cooled, it will be better borne by the stomach. " 

Prophylaxis. — Absolute exclusion of the genu of yellow fever from 
any locality is an absolute preventive of the fever ; hence the importance 
of a most rigid quarantine, the isolation of the sick, and the complete 
disinfection of clothing, excreta, etc. It is of the utmost importance 
that infected districts be immediately depopulated. Keeping away 
from an affected district is the only prophylaxis. 



CHAPTER XLVI. 
DENGUE (BREAK-BOKE FEVER). 

Definition. — Dengue is a febrile epidemic, contagious fever of sub- 
tropical countries, characterized by violent muscular and articular pains 
ainl a polymorphous rash, and often dichronous, and by a cyclical evolu- 
tion in four periods, the last being that of convalescence, which is 
prolonged and difficult. It is, as a rule, not a fatal malady. 

Etiology. — Epidemics of dengue have been noted in subtropical 
Asia, Europe, and America. J. W. McLaughlin states that he has 
found a peculiar micrococcus in the blood. The disease is immediately 
contagious. It is said that four-fifths of the whole population exposed 
take the disease. 

Symptomatology . — The period of incubation varies from a few 
minutes to five or six days (Fayrer) and averages four days (Catho- 
lendy). Dengue commences abruptly with very severe aching pains 
and headache, and usually reaches its maximum during the first twenty- 
four hours. In severe cases there are rapid pulse, general adynamia, 
and even nocturnal delirium. Loss of appetite is universal ; mucous or 
bilious vomiting is very common. Very frequently there appears 
almost at once an erythematic rash, which may invade the mucous 
membrane, producing redness and swelling of the conjunctiva, of the 
internal nares, and of the throat. Both large and small joints are 
affected, and often become swollen and red by the third or fourth day. 
In from forty-eight to sixty hours a rapid defervescence occurs, often 
accompanied with critical phenomena, such as colliquative sweat, diar- 
rhea, and epistaxis. At this time in a large proportion of the cases 
the so-called secondary or terminal rash of the disease develops, which 
is characterized by its polymorphism. It may be papular or circum- 
scribed, or papular and diffused, or it may be vesicular or pustular. 
Several forms of the eruption may exist in the same case. Enlarge- 
ment of the lymphatic glands is not uncommon. A secondary fever 
may follow the eruption and gradually subside. 

In infants and younger children, as Thomas and others have 
observed, the disease often begins with a convulsion, a child being 
awakened at night with a spasm. If the child is old enough to speak, 
it will complain of feeling cold or chilly along the back, and shortly 
after of headache, rachialgia, and ortheralgic pains. During an epi- 
demic these symptoms should awaken the physician to a suspicion of 
the disease. The behavior of smaller children, of infants especially, 
will depend almost entirely upon the intensity of the attack. Sud- 

(598) 



Dengue. 599 

den restlessness, agitation, and manifest discomfort, with constant cry- 
ing or moaning, and not infrequently repeated vomiting, especially of 
breat-milk in nurslings, are special symptoms. More serious are those 
cases in which infant or child, after having had a convulsion, remains 
listless, apathetic, or in a stupor. In these cases the gastro-intestinal 
disturbance is more pronounced, vomiting being quite frequent, the 
vomit usually consisting of ingesta, mucus, gastric secretions, and bile. 
These cases are almost always associated with high temperature, and 
will need careful watching. Xo matter how the attack begins, an 
indefinable prostration seizes the patient, and fever begins. In an 
adult the pulse becomes hard and rapid, oscillating between 100 and 
120 and even 140 (Twining) to the minute. In younger children the 
pulse is often so frequent that it is impossible to count it. 

The respiration in children is hurried in proportion to the fever. 
The temperature begins to rise at once, and attains its maximum 
usually in from twelve to twenty-four hours, rarely after three days, 
and very rarely after five or seven days. 

The fastigium is generally very short, and the defervescence is 
rapid and characterized by a succession of remissions and exacerba- 
tions, which continue until the temperature has fallen one or one and 
a half degrees lower than the natural heat of the body. 1 During the 
next few days, if the temperature is closely watched with a thermom- 
eter, it will be found that it fluctuates from a degree below to one or 
two degrees above normal heat. At the end of the sixth or seventh 
day, there is a very slight rise again, being a secondary fever, but, as 
a rule, this heat soon subsides, and the temperature remains normal 
unless there is relapse, which is not uncommon even in the mildest 
forms. 

Relapses. — The frequency of relapses is universally admitted as 
being one of the distinct features of the clinical career of dengue. 

Prognosis. — Dengue almost invariably ends in recovery. 

Differential Diagnosis. — "Absolute diagnosis of dengue is exceed- 
ingly difficult to establish in the beginning of an epidemic ; when once 
the epidemic has been recognized and admitted, the diagnosis is not so 
difficult. 

"Treatment. — This is a self-limited disease, almost always ending 
in recovery, with rarely a call for therapeutic interference. All medic- 
inal agencies are stated to have been practically nil. In the majority 
of tropical diseases an evacuant medication at the onset seems generally 
to be followed by good results, and experience has tested the fact that 
dengue is no exception to this general rule. For this reason it will 
be proper to begin the treatment of the first stage by administering an 
emetic of syrup of ipecac, followed after the emesis by a laxative. 

'Tor infants at the breast, aromatic syrup of rhubarb is a very 
generally-administered and popular laxative. Several large spoonfuls 
l ~Dv. D. Aquin, of New Orleans; confirmed by Vauvray, M. D. 



600 Dengue. 

of prune tea, sweetened with syrup of manna, will also act efficiently in 
the same direction, and may be given to advantage to older children 
where the tea is combined with a few leaves of senna. Cream of tartar 
or magnesia in lemonade will be found palatable, if iced, even by the 
most fastidious and difficult children. After the laxative, a hot mus- 
tard foot-bath relieves the intense headache of the invasion. For con- 
vulsions in infants, the warm mustard bath will be found beneficial, 
prepared according to Trousseau's recommendations, by simply immers- 
ing a small bagful of mustard meal in a tub of hot water and pressing 
the bag in the water without mixing the meal in the water. Potassium 
bromide is very effective in diminishing the reflex excitability of chil- 
dren, and will prove more than usually effective in this condition. 
Wet cups to the back of the neck in marked cerebral hyperemia will 
greatly lighten and relieve the head-symptoms. Good judgment is 
necessary in the exhibition of this depletory treatment, which should 
be reserved for sthenic and plethoric children and adults. Cold appli- 
cations to the head, iced in summer, with camphorated sedative water, 
bay rum, or cologne, will always be grateful to the patient. The phy- 
sician should demonstrate the use of cold water in hot climates in the 
country where parents are afraid to use cold water, for some mysterious 
reason. The little patient should be laid across the bed, with its head 
projecting beyond the edge of the bed, allowing it to rest in a bowl of 
water mixed with evaporating lotion, ice being also added if the initial 
headache is very intense. The head should then be gently but freely 
douched with water. A little shampooing of the head, aided by fanning, 
will complete the process, and the patient will be made thereby infi- 
nitely more comfortable, no matter what age. By this means alone the 
convulsive manifestations and agitations of many children will be 
lulled and averted." (Matas, M. D.) Thomas says that in cases 
of adults exhibiting the rheumatic type, particularly when the tempera- 
ture runs high, sodium salicylate will be found to be very efficient, 
safe, and pleasant. Matas states that there is no question at present 
as to the superiority, reliability, and safety of the use of antipyrine. 



CHAPTER XLYII. 
XURSI^G OF SICK CHILDREN. 

To a casual observer sick children may seem all much alike in 
their restlessness, and in their perpetual demand on the patience and 
care of their attendants, and yet to the practised eye there is every 
shade of difference in the characters of children, each little child hav- 
ing as strongly-marked peculiarities as adults. The little people 
demand study and thought on the part of those who attend them; and 
all who have experience in the care of sick children will soon realize 
that some education and training are required for those who aim at 
nursing them successfully. How often do we hear mothers say, who 
have raised a family of children in which no two are alike, that some 
of them would have to be coaxed, others ruled with a stem hand, etc. ! 
Even the little babies differ one from another. In the study of these 
various dispositions or idiosyncrasies, and in the adaptation of means 
to an end, a real children's nurse sees at once that, though her duties 
should be performed methodically and with regularity, each child must 
be the subject of special study, and rules and "red tape" made suffi- 
ciently elastic to cover all. 

Dr. West, who was a pioneer in initiating a specialty in the treat- 
ment of sick children, says in his opening lecture to students: "Chil- 
dren will form at least one-third of all your patients. So serious are 
their diseases that one child in five dies within a year after birth, and 
one in three before the completion of the fifth year. These facts, 
indeed, afford conclusive arguments for enforcing on you the impor- 
tance of closely watching every attack of illness that may invade the 
body while it is so frail." The child will not be nursed by any one ; 
it is elective in its tastes, and those who aim at nursing sick children 
must have the art of winning the child's love and confidence at the 
commencement. The training of the mother or nurse may be based 
on the power to observe, to interpret aright these observations, to under- 
stand and anticipate the wants of the patient, to comprehend the 
emphatic but unspoken language of the aspect, manner, cry, posture, 
etc., of sickness. It must be the first object of the nurse to learn 
these, or she will fail in her task ; and she must also bring to her aid 
patience, gentleness, cheerfulness, good temper, and self-restraint. 
The child may be refractory, and she will have to learn how to feed 
such children ; she will have to grasp the method and science of giving 
food so as to sustain the strength and yet not overtax the digestive 
powers; she will have the most irritable stomach as well as the most 

(601) 



602 Nursing of Sick Children. 

rebellious ones to deal with; and above all she will sometimes have to 
harden her heart to the pathetic petition for indulgences or treats. 
Firmness and gentleness will have to be combined, how to insist, how 
to win obedience without friction, how to keep the patient quiet under 
all difficulties and under all circumstances, — these things are accom- 
plished by love and truthfulness. Once win the child's confidence, 
and then it will yield itself to all demands. Truthfulness must be 
the watchword, and should be insisted on from all those who have to 
tend the sick child, even when it wrings the loving heart to speak the 
truth. It pains the child to be deceived, especially when among 
strangers. 

To see a sick child lie quiet in its crib and thankful to be let 
alone is touching indeed ; and it is this letting alone which is so impor- 
tant in nursing a sick child. The poor mothers in their own homes 
make quite a toil of their children; they will hardly put them out of 
their arms, and they will not believe that the child can be thriving un- 
less they are dandling it on their knees ; both mother and child are quite 
wearied. It is the greatest kindness to let the child lie quiet in the 
crib or cot. The child thrives better and gets a better supply of fresh 
air. Sick children should not be kissed about the mouth or face. The 
back of the neck or the hand is the best place to be kissed, but it is 
better not to indulge in much kissing during any kind of illness. It is 
difficult sometimes to accustom the child to lie quiet. At first it will 
be restless, and fret at not being taken up ; but when it sees that fret- 
ting is of no avail, with the ready adaptability of childhood, it learns 
to make the best of it, and the little face soon loses the worried look 
that is so often marked on the faces of children, and a look of happi- 
ness and content will be seen. 

Children can not thrive in a darkened room. The light and plenty 
of fresh air should flood their apartment, but must not pour in directly 
upon them. Children are like the plants in the garden. Plants grow 
and expand under the rays of sunlight, and we know there can be no 
doubt that the light has a physiological influence on the growth and 
development of children, especially in cases of illness. The sick-room 
should have a southern or western exposure, and a free circulation of 
air, interchanging with the outer air without making a draught, should 
be kept kept up day and night, especially in crowded cities. 

THE SICK CHILD. 

Any deviation from the standard of the child's health affects its 
sympathetic nature; it at once gives token that there is something 
wrong, some morbific influence at work. The rapid course of a severe 
onset of an illness, and its speedy termination either in recovery or in 
death, are always matters of surprise to those unaccustomed to sick 
children ; hence it requires that the attendants be fully on the alert to 
catch each new symptom, and be prepared with appropriate treatment. 



Nursing of Sick Children. 603 

The mother should not wait until her child's illness has declared itself 
before she takes action ; and even then, as a mild domestic ailment and 
an acute disease may assume the same symptoms, she should act with 
judgment and seek some skilled assistance ; for however experienced a 
mother may be, she can hardly read symptoms aright. Or there may 
be one of the infantile infectious complaints setting in, and then for 
the sake of other children some system of isolation is necessary. 

Usually illness first shows itself in a child by listlessness and loss 
of appetite ; the eyes look heavy ; the child may be fretful, especially if 
disturbed, or it may be drowsy ; it will feel hot, and if the temperature 
is taken, the thermometer will show generally an elevation above the 
normal. This must not be disregarded, as a very little suffices to dis- 
turb the normal heat of the body. In nearly all cases there will be 
vomiting and some bowel disturbance, and special symptoms will soon 
be observed. In older children who are able to explain their feelings, 
the symptoms set in in the same manner, and heed must be given that 
something is amiss. We usually wait awhile and see what is coming 
on, watching the child carefully, and placing it in a quiet room and 
away from other children, giving it light food of easy digestion, seeing 
that the bowels are not overloaded, and waiting for the diagnosis of 
the family physician or some good physician. 

AGE. 

It is to be borne in mind that age has much influence on the dis- 
eases of children ; that before the age of seven years the body is being 
built up rapidly, and this means a great expenditure of vital force. 
From this fact it is easily understood that a small disturbing cause will 
seriously upset the equilibrium of its powers. It is of more impor- 
tance to keep a child in health than to restore it from illness to its nor- 
mal condition; and very much may be done by regularity in all its 
habits. Appropriate, food at regular intervals will aid the digestive 
powers into strong, healthy action ; regular hours of rest and exercise 
will soothe and strengthen the nerve centers ; the muscular powers will 
be developed by use, and the mental faculties develop themselves in 
harmony with the animal vigor. Dentition is a certain crisis in a 
child's life, causing a great many disturbances, and great anxiety to 
the mother; through this crisis it needs to be carefully steered, and it 
will pass the teething period in safety. It is a natural process, for 
which provision has been made in the child's constitution; and if its 
surroundings and habits are healthful, it w^ll pass through the storm 
with but little danger. Hereditary defects that are ever present in 
children will often modify acute disease by their influence. If the 
mother will study her child's constitution, she can do much to defend 
the weak points by maintaining a wholesome habit of living. Xo two 
children are alike, and they will thrive the best who receive the most 
individual thought. 



604 Nursing of Sick Children. 

The nursery or the child's playhouse, if it is in the country, should 
by no means be thought of secondary importance; here the child will 
spend three-fourths of its day, and its surroundings will never die out 
of a child's life. It is very important that it be bright, cheerful, and 
clean, and the mother should preside over the children and teach them 
that order and method should rule their habits. The little ones will 
then look back upon their nursery days as some of the brightest in 
their lives. 

THE SICK-ROOM. 

It is very essential that as far as possible the management of the 
sick-room should be kept in the hands of one person, so that there may 
be unity of treatment and that methodical harmony which is of. so 
much importance in sickness; and then if the assistants are obedient, 
good work may be done. Fidgety nursing does harm more often than 
otherwise. All unnecessary articles of furniture should be removed 
from the room, also the hangings from the wall if there are any, and 
the carpet; have at hand everything that you can that is likely to be 
needed, as extra basins, cups, small pans for the linen feeders, a supply 
of hot water for baths, and a ready supply of linen, etc. A good plan, 
where there is sickness in the country, is to keep all white cotton rags 
boiled, then rolled up and put away in a clean place for emergencies. 
Keep all these appliances handy; but they should be kept outside of 
the room, and also outside have vessels for receiving the slops, so that 
there may be nothing offensive about the patient. Provide a good sup- 
ply of some disinfectant in a concentrated form (soda, bicarbonate, 
chlorate of lime is easily obtained in the country, and let the soda be 
used freely on the floor, as it has no offensive odor). The lime may be 
used in the vessels, and for soaking the bed-linen when removed from 
.the patient. 

Next is the choice of the sick child's nurse, which is of much 
importance. We want a steady, reliable woman, who can manage the 
patient with patience and kindness and firmness, who can be trusted to 
carry out orders, and yet have a discretion of her own. She must be 
cheerful and even-tempered, physically strong, cool, and self-possessed 
in an emergency, and above all with a love for her work and her 
patient. The mother must frequently have the nursing to do in the 
country, as trained nurses can not be had. Hence every mother should 
study how to nurse her children. City mothers have the advantage of 
trained nurses, which is one of the best earthly blessings. The wise 
nurse will show herself to be a woman of tact and sympathy, will soon 
infuse her spirit into the members of the family, and they will readily 
work under her guidance. 

The advice to the hospital nurse may as well be applied to the self- 
trained country nurse. There are many little niceties of method and 
order chat will add to the comfort of the patient. A child with any 
form of fever is easily washed in the recumbent position on a blanket 



Nursing of Sick Children. 605 

or a Turkish sheet, being rolled gently from side to side; in the case 
of an injured limb it must be steadied with one hand or by a second 
person, and then there is very little pain or displacement. It is a great 
husbanding of the strength in fever, especially typhoid, to keep the 
patient always lying down, and the whole of the person can be prop 
erly washed in this way. This is the best preventive of bed-sores, 
especially in cases of paralysis, where the evacuations are not retained, 
and enables the nurse to see at once any weakness of the skin. The 
skin must be completely dried, and dusting-powder liberally used, and 
then a child can lie for months on his back, provided the sheet is 
stretched tightly and pinned down, not allowing any wrinkles what- 
ever to get under the child's hips. After the bath and drying the 
back and hips, it is a good plan to bathe with alcohol, then dry the 
parts again and apply the dusting-powder. The child's clothing 
should be so arranged that a physical examination can be made quickly 
and without undue exposure. Sometimes it is trying for a physician 
to wait for the nurse to fumble at the strings or buttons, and it wor- 
ries the child. Before or about the time you expect the doctor's visit, 
the nurse should have the clothing loosened, and a blanket warming at 
the stove to wrap the child in, if it is to be taken out of bed. If the 
child is examined in bed, the nightgown and vest are drawn over the 
head and placed near the stove to keep warm. This is an important 
little detail which doctors appreciate, and it is important for a delicate 
child to be saved the chill of cold garments, especially when tired by 
the examination. A loose wrap will serve to cover the parts not under 
examination ; have a warm towel at hand if it is the doctor's custom to 
use one while examining the chest, and be sure it is well aired. Should 
the doctor prefer to examine the child on the mother's or nurse's lap, 
a warm blanket may be wrapped around the child, or lay the blanket 
over the lap where it will be easily adjusted to the doctor's convenience. 
Sometimes a few moments' time is necessary to win the child's con- 
fidence and allay its fears. If no anaesthetic is to be used, it may be 
best to tell the child that it may hurt a litle bit if instruments have to 
be used, but they should be kept out of sight, as the sight of the instru- 
ments may frighten the child. It is always best to treat children with 
candor. 

Remember, in putting on hot applications, that a child's skin is 
more sensitive and tender than an adult's (and some adults are more 
sensitive than others). The child's sensation must be the guide. It 
is a cruel thing to put on a poultice or a fomentation too hot ; it does 
no good if it burns and excites the child. The physician will usually 
instruct the nurse how to put on a blister, and how to dress it after- 
ward. After applying any kind of blister, a warm corn-starch poul- 
tice, saturated with sweet-oil on the side that is to be laid next to the 
blister, should be put on, and then covered with absorbent cotton, and 
afterwards with a bandage. Cheese-cloth or an old linen handkerchief 
is good to hold the poultice, but it must be very clean. After the poul- 



606 Nursing of Sick Children. 

tice has remained on long enough, it may be removed ; and with a pair 
of sharp scissors the blister should be clipped on its lower side, press- 
ing absorbent cotton on a clean cloth just underneath to absorb the 
water that runs from the blister. Then have at hand a new warm 
poultice with the oil the same as above prescribed, and apply it over 
the blister. Dress the blister a day or two or longer till it stops dis- 
charging yellow water ; then sterilized vaseline may be put on till it 
heals. If the blister itches very much, it may be bathed in camphor 
water with a little laudanum in it to stop the itching. 

The administering of food or medicine by means of an enema 
in ^ the same manner is usually prescribed by the physician. All 
mothers should be well versed in this method, as it is so often neces- 
sary in case of diarrhea in children and to check diarrhea. The bulk 
should be made as small as possible in some instances. To check diar- 
rhea, it will probably consist of corn-starch and some kind of astringent, 
perhaps opium, and there should not be more than two or four teaspoon- 
f uls of mucilage with the quantity of opium prescribed. If you are go- 
ing to deal with constipation, it will be large in quantity, such as a pint 
of soapy warm water, or gruel and castor-oil, or soap and castor-oil; 
and after the injection has been given, leave the patient quiet until 
there is a desire to return it. To give the enema for constipation, 
the tube should be oiled and passed up the rectum very slowly and 
gently as far as it will go. In giving a nutrient enema, the food must 
be as concentrated as possible, and be a little thickened with starch 
powder or arrowroot. Four ounces is as much as the bowel will retain. 
It is better to first wash out the rectum with a little warm water, 
then wait about half an hour before giving the food enema, 

Mothers who are not trained nurses should remember to save 
/ a little of the morning urine for the doctor for testing ; put it in a clean 
covered vessel. The doctor may want a record of the amount passed 
in twenty-four hours ; in such cases a jar or vessel is provided, and then 
the observation is begun from a fixed hour — say 8 a. m. On the first 
morning let the child pass the urine at that hour (or any other hour 
that is most suitable for the nurse), and throw it away; all the water 
passed subsequently up to 8 a. m. the next morning is to be saved, and 
the whole quantity is measured, recorded, and thrown away. If the 
specific gravity is to be taken, the nurse must be shown how to use 
the little instrument that weighs it, and how to record it, by the attend- 
ing physician. The evacuations should be saved, and reported as to 
their condition, and in case of doubt, for inspection. There is a diver- 
sity of opinion as to whether diarrhea exists or not. A little looseness 
is called diarrhea by some. The presence of slime and blood in the 
stools should be reported at once; also any passing of undigested food. 
The frequency and the quantity must also be observed and reported, 
and intelligent answers given to the doctor's questions. 

Management in Sickness. — Bad management in the diseases of 
young children is frequently seen, and yet the medical attendant has 



Nursing of Sick Children. 607 

to rely very much for the success of his medicines upon the intelli- 
gence and good management of the nurse. Hence the great importance 
of all mothers acquainting themselves with the rules that govern nurs- 
ing. The question is, What is to be done with a child who will not 
take milk, when that is the special diet indicated by its complaint % 
The popular feeding-bottle with the india-rubber tube is often offensive 
to the child, because it is almost impossible to prevent decomposition, 
which will take place from particles of food clinging to the inner side. 
This will taint the most carefully-prepared food. The bottle and 
nipple need careful scalding and rinsing, and should be kept in a cold 
vessel of water between times. In all probability the diarrhea of an 
infant must be looked for first as coming from the bottle. In diar- 
rhea and vomiting the administration of food has much to do with 
the recovery ; first of all, suitable quantities for digestion must be given 
at regular intervals and with patience, and it must be freshly prepared. 
All the vessels used for preparing the food must be scrupulously clean ; 
in fact, there should be one special vessel set aside for the sole pur- 
pose of preparing the child's food. 

In all diseases of the respiratory organs, the child requires a warm 
room with an even temperature. But the room must have sufficient 
ventilation to insure against a stuffy, poisonous atmosphere; and this 
result can be obtained by keeping the room at a constant even tempera- 
ture, with a free interchange of fresh air. This requires a little fore- 
thought and management, but it can be done. The essential is that 
the exetrnal air, which is the freshest, should be admitted steadily, 
and the temperature kept from falling below 60 degrees Fahrenheit. 
The mother or trained nurse must bring this about by her ingenuity; 
but it must be remembered that letting in the used-up air off the stair- 
case and passages is not ventilating with fresh air ; the air must come 
directly from outside to do good. It is necessary to moisten the air 
with steam, and this is best done, for instance in case of laryngitis, 
by surrounding the bed with some light curtain or screen, and then 
letting the steam come from some suitable apparatus into the bed 
near the patient, care being taken that there is an escape from the 
top of the bed, or the curtains will become damp. A teakettle kept 
boiling on the stove or near the side of the fire will be found beneficial 
in all cases of sickness where it is best to have the air kept moistened. 

A few hints for dealing with diphtheria or laryngitis are all 
that will be necessary in this article, as these diseases have been 
treated in other articles. There are few cases that demand more 
skilled nursing than diphtheria ; and when it is possible an experienced 
nurse should attend on such cases, especially after the operation of 
tracheotomy, as careful feeding and watching by an experienced nurse 
are essential to recovery. The attendant should keep her mouth closed 
while standing over the patient, and. use a disinfectant for washing 
the hands before taking her meals. A lotion or weak solution of car- 
bolic acid should be put near the bed for washing the sponges, etc., 



608 \ Nursing of Sick Children. 

that are used about the patient, and all feeding cups, spoons, and 
glasses must be kept apart. Linen over a piece of waterproof pinned 
over the neck of a child's nightdress to make a bib, is a clean way of 
keeping the neck dry; for it must be remembered that the diphtheritic 
discharges are most irritating to the skin. The nurse's skill, patience, 
and vigilance will be taxed in dealing with such cases. Her patients 
will require incessant watching, and will make endless demands on 
her ingenuity. It is advisable to use clean, soft rags, which can be 
easily burned. Never use pocket handkerchiefs. 

In homes where there are infectious diseases a great deal can 
be^ done by way of precaution in the use of disinfectants for the linen 
and the discharges before they are taken out of the room, as it is in 
these that the germs of disease are conveyed. A sheet kept moistened 
with some disinfectant and hung over the outside of the door of 
the sick-room is very effective. Then of course there should be no 
intercourse between the occupants of the sick-room and the rest of 
the household, and the nurse and friends should change their garments 
before going out. The floor of the sick-room should be swept with 
sawdust moistened in the disinfectant, and if possible all the dust 
and refuse should be burned. 

In case of scarlet fever in the desquamating stage, it is the prac- 
tise of some doctors to have their patients rubbed over with an oint- 
ment; others say that oil retards the process of desquamation and 
closes the pores of the skin. I always prescribe a thorough aseptic 
bath — first sponge with weak carbolized water, then wash with hot 
water with plenty of soap; or rub the entire body with dampened 
soda, then sponge off till very clean, removing all desquamation; rub 
the body till dry and then anoint with cocoanut butter. But what- 
ever treatment the attending physician prescribes should be adopted. 
The skin must be kept clean by. frequent sponging with warm water, 
and the patient kept in bed until the process is over ; remember always 
to do the sponging under a blanket. Every precaution should be used 
to keep the dust from the bed from being scattered about. 

The desquamation from a case of measles is not so easily dealt 
with ; it starts infection in the early stage, before the eruption has 
thoroughly developed, and so spreads among a household before it is 
checked. It is of importance to keep the patient in a warm room, 
in bed, until the eruption has shown itself. The same rule of disin- 
fection will apply to this disease as to all other infectious diseases ; 
the patient must be kept in bed till the eruption has disappeared, and 
longer still if there is any tendency to lung disease, as is so often the 
case, which is shown by a continuous high temperature and the state 
of the breathing. The diet should be light in this and all other 
eruptive diseases, very nourishing, and with but little animal broth or 
tea in it, as this is apt to be overstimulating, except in cases of great 
prostration, when animal broths are prescribed. 



Nursing of Sick Children. 609 

Every mother who raises a family of children should learn of 
physician or druggist how to use a fever thermometer, which will 
be of great assistance to her in ascertaining a child's temperature. 
With this knowledge she will never be too late in calling in assistance 
to save an illness of long duration, and in many cases the life of a 
child. Pneumonia and measles often occur together. In the case of 
measles the fever begins to fall about the third day; but if it per- 
sists high or rises above 103 degrees Fahrenheit, then the mother or 
nurse must be on the alert for some complications, and must look out 
for all symptoms that may aid the doctor in detecting the mischief, 
and she must keep the patient warm and lying down, while she pays 
attention to the evacuations, and supports the strength with careful 
systematic feeding. Always notify the doctor if there is a sudden 
rise of temperature, shortness of breath, and coughing, etc., compli- 
cating measles, as you are likely to have a case of pneumonia to deal 
with. 

One great essential in nursing is, scrupulous cleanliness, in all 
cases of illness, in the person of the patient and in all its surroundings. 
A sick child should be washed all over every day and sometimes twice 
a day; every part of its body should be examined, that the first sign 
of a sore may be detected, or any change in its condition, such as swell- 
ing, discoloration, or enlargement about the joints, and such informa- 
tion should be handed over to the attending physieian at the earliest 
opportunity. In the case of young babies, their skin requires wash- 
ing and drying each time the napkin is changed ; a nurse who knows 
her work, and all mothers, should be able to keep a child clean and 
its wants anticipated without giving in to lazy ways. If the patient 
is to be kept clean, the bed must be kept clean likewise, and all soiled 
linen must be at once taken out of the house, not pushed under the 
bed out of sight, as is often the case, nor one wet end of the sheet 
tucked under the mattress, but must absolutely be put in its proper 
receptacle, where it will do no harm. Every mother should have 
a few draw-sheets put by for use in case of sickness. The hospital 
draw-sheet is very necessary for a sick-bed; it can be quickly drawn 
away without much disturbance to the patient and quickly substituted 
for another. A draw-sheet is a long, narrow sheet, about one and one- 
half yards long by three-fourths of a yard wide, of a coarser material 
than linen, and is placed under the body of the patient, sometimes 
with a square of rubber under it ; it is then well tucked under the sides 
of the mattress, and pinned down, and serves also to keep things straight. 
Feeding. — The importance of feeding can not be exaggerated; it 
is a subject of growing interest the world over. ^ine-tenths of the 
ailments of children are said to be due to some error in the feeding; 
and it is generally conceded that many lives are lost in cases of sick- 
ness which might have been saved if only the nurse had understood 
something of the art. of feeding the sick. And it is art; indeed, it 
should be placed above every other art in this twentieth century. 



610 Nursing of Sich Children. 

Delicately-prepared and properly-seasoned food will invariably quiet 
the child, and it is the same with adults. An angry father has been 
known to make peace with his wife after he had partaken of food 
daintily prepared by her own hands. The preparing of food for a 
sick child is no ordinary matter ; it is a complex problem. There are, 
in the first place, varying ideas as to the quantity that a child should 
consume, and as to the frequency with which such food should be 
given, also as to its component parts. Nature's standard has been 
given as to what is the proper food and the proper quantity for the 
infant, and from this she intends us to work out the problem. In the 
constitutionally weak child, that has to be brought up by means of a 
feeding bottle, it is very difficult ; the child's diet must be carefully 
studied, and then that food which seems best suited to it must be 
adhered to. In dealing with these difficult cases, common sense must 
be used ; all theory must be set aside, and that food used which agrees 
the best with the child. It will be found that in the case of weak 
children, five drops of brandy to each feeding for twenty-four hours 
or so, will often give the tone and vitality to the stomach which it has 
lost through weakening diarrhea and vomiting. 

In feeding, system is most essential. Let us suppose that a child 
has to take one and a half or two pints of food in twenty-four hours • 
then let this be divided into equal quantities, to be given at equal inter- 
vals of time. Suppose the diet consists of one pint of milk and one 
pint of beef tea, with some stimulant, then it will be found that an 
alternate feeding of two ounces every hour will use up the quantity 
in the time. This mode of feeding, it will be seen, naturally applies 
in its frequency to serious illness, where the strength requires such 
sustenance ; but where the child's condition permits, the stomach is 
allowed to rest at night with the body. Night feeding is not as essen- 
tial as the day ; a little nourishment given early in the morning, when 
vitality is low, is of great value. Rational and systematic feeding in 
typhoid fever is about all the treatment; not much else is required, 
but good food adapted to such cases and good nursing, with antiseptic 
precautions and cleanliness. As long as the high temperature keeps 
up — and that usually runs three weeks or sometimes four — the patient 
is kept strictly on a mild and liquid diet, such as milk (buttermilk 
or koumiss for adults) and beef tea with no admixture of bread or 
starchy foods. All outside interference from relatives, who often mean 
well in suggesting various articles of food, must be sternly set aside. 
A useful mode of feeding when a child is refractory, or when from any 
other cause it can not take its food, is through its nose. Skilled hands 
only can administer food in this manner, as in unskilled hands it may 
be fatal. 

Bathing. — Most children like their bath, although some dread 
it; fear of the bath is sometimes caused by roughness in washing the 
child, or by hurrying it too suddenly into a bath. A child can be 
taught to enjoy a body bath from birth by proper and careful handling 



Nursing of Sick Children. 611 

from the first. Xever have the water too hot or too cold — just a lit- 
tle more than blood heat. Rickety children are very tender to the 
touch, and require gentle manipulation when in the bath. 

The bath is essential for both sick and well; hence the mother 
and nurse must use special gentleness in giving the bath so that a child 
may overcome its fear. The temperature of the bath should be about 
98 degrees Fahrenheit. It can be tested by the use of the thermometer, 
or it may be just comfortable to the back of the hand (must not be 
what you call hot). When the bath is over, have at hand a warm 
blanket or Turkish sheet, either of which is desirable, on which to place 
the child while being dried ; this must be done quickly, with a warm, 
soft towel, and warmed garments put on quickly, and the child placed 
back in the bed. Remember to have a fresh, clean bed made for the 
child while the bath is being given. If a douche bath is ordered, 
and the regular appliances are not handy, place the child in an ordinary 
warm bath, standing, if possible, and then pour a jug of cool (not 
cold) water down the spine from a height ordered by the doctor, 
onto that particular part for which the douche is ordered. Rub the 
part, well with a rough towel, so as to get up a good circulation, and 
knead it with the hands. If a bath is ordered to reduce the tempera- 
ture, its temperature should be 65 degrees Fahrenheit. The bath must 
be brought to the bedside, the patient lowered into the bath on a blan- 
ket, and kept in for five or ten minutes, according to the doctor's orders, 
then removed from the bath, dried quickly, and put back into bed. 

The morning and evening warm bath for young children should 
be a part of the daily program, and in babies it is most essential that 
the pores of the tender skin should be kept freely open and healthy. 
A soft piece of linen may be used for washing, or a very fine soft 
sponge, and then the body carefully but tenderly dried; pure castile 
soap is the best for washing infants. For older children the bath 
may be made tepid until they are strong enough to take a cold bath. 
In administering the cold bath, keep the feet out of cold water, then 
give a dash of cold water all over the body (after the body has been 
washed with warm or tepid water) with a large sponge, and dry the 
body quickly. If the surface is blue, the reaction is imperfect, and 
in such cases the tepid bath only must be used, as the shock of the 
cold water is too great for the system. No child under seven years 
of age should take a cold bath. It is very essential in all bathing 
that the skin and hair be dried thoroughly and quickly. A nervous 
child may be given something to play with while bathing, to distract 
its mind from the bath. 

The clothing of the sick child should be loose, light, and easily 
changed. A sick child needs some warm jackets to put on during 
the daytime while confined in bed, as it does not keep covered, like the 
adult, and its shoulders and chest need protection. All bedclothing 
must be light and warm, not doubled in a heavy fold over the chest, 
as is so often the case. 



612 Nursing of Sick Children. 

When a child is convalescing, it is necessary that the surface 
of the body be thoroughly well covered with light, warm clothing, 
made loose; woolen clothing is more suitable than cotton, and is 
lighter. Never put a stiff garment next the child's body; all binders 
of all kinds are a mistake ; they interfere with the free use of the 
muscles. In sickness the flannel vest and the bedgown require fre- 
quent changing. All sick children should have a gown put on fresh 
for the night ; it gives rest to the patient. In surgical cases the bed- 
gown should be open down the whole length ; the same applies in adult 
cases as in typhoid fever. 

In arranging bedclothes where a child needs to have a bed-pan 
placed under it, a circular bed-pan put under a circular air-cushion, 
and the sheets arranged accordingly, will keep the child quite dry, 
as in case of operation for a stone in the bladder. A hair mattress 
put onto a box mattress is the best bed for all patients. The springs 
should be stiff, and must not sink down about the hips, as such a bed 
is very wearing on the patient. A board placed over a hair mattress 
with a hair mattress over the board makes the best bed for children 
who have a rickety spine, and is best for all growing children. Put 
two sheets on the bed, folded straight down the center, so that they 
can be easily withdrawn, and kept in place with a draw-sheet, and 
then the rest of the clothing is arranged so as to give the most warmth. 
Do not allow any creases to get under the hips or shoulders of the 
child, and thus avoid bed-sores. The pillow should be changed daily 
and aired often. If small pillows are required to support a limb, 
these should be firm, like sand pillows, and as small as possible. Every 
appliance must be made and adjusted so as to suit all cases. It 
takes constant care, great patience, and minute attention to nurse a 
sick patient, either child or adult, back to health, but it can be 
accomplished. Nothing is too small which contributes to such an 
object, and success will attend upon careful thought for all these 
details. The mother is amply repaid when she sees her child return- 
ing to health again, bringing joy and sunshine to the home. 



CHAPTER XLVIII. 
DIARRHEA. 

SIMPLE DIAEEHEA. 

Etiology. — Predisposition is the same for this as for all other 
varieties of diarrhea, — age, under two years, bad intestinal hygiene, 
such as bad habits of breathing, improper food, unsanitary surround- 
ings, and the warm season. 

The most important special causes of this variety are those acting 
upon the nervous system. As such may be classed dentition, chilling of 
the surface, exhaustion from fatigue or other causes, and the first 
effects of atmospheric heat. Exhaustion and heat are very much more 
frequently associated with dyspeptic diarrhea, but not always. The 
same may be said of menstruation and various nervous impressions 
upon the mother of a nursing infant. As we know, a nervous mother 
does not always produce healthy milk for her infant. 

Foreign bodies, or articles of food which are virtually foreign 
bodies — such as uncooked or partly cooked grains of rice, hominy, bar- 
ley, or green corn, or green fruits, nuts, or raisins in the case of very 
small children — any of these may be the cause of simple diarrhea. 
Certain fruits, such as peaches, pears, grapes, etc., make slight diarrhea, 
from the organic acids they contain, or from their seeds acting mechan- 
ically. 

Diarrhea may be due to any one of the various cathartic drugs, in 
which the normal physiologeal effects have, from the susceptibility of 
the patient, been very greatly exaggerated in intensity or prolonged. 
A hyper-secretion of bile is generally believed to be a cause of diarrhea. 
Such causes are thought to be rare. Ice-water is thought to cause an 
attack of diarrhea, apart from any other visible cause. 

Pathology. — In these cases we have neither intestinal decompo- 
sition nor intestinal inflammation as the cause of the symptom. There 
is increased action of the bowels, of reflex origin, or depending upon 
local irritation, increased secretion, chiefly serous, and in most cases a 
moderate hyperemia. If the exciting cause continues operative, the 
case may go on to intestinal inflammation. 

Symptoms. — These may come on suddenly or gradually. If sud- 
denly, there is usually abdominal pain preceding the diarrhea; other- 
wise this is absent. There are at first one or two soft, faecal stools; 
then they come quite thin, and may be watery. There may be as many 
as eight or ten in a day. There may be restlessness in case of infants, 

(613) 



614 Diarrhea. 

and at all times there is a great deal of exhaustion, and often a clammy 
skin from perspiration. But there is no vomiting, and the temperature 
is not elevated; these two negative symptoms quiet at once the appre- 
hensions that may have been felt regarding a more serious illness. The 
stools are not often green in an infant, but are a pale yellow or gray 
color; in older children they are thin and brown or gray, and in all 
there is more or less odor. If the cause has been some material acting 
as a foreign body, this may be found in the discharges. If left to 
themselves, these cases usually recover in three or four days ; but they 
may develop into more serious forms of intestinal disease, particularly 
if it is in summer. If the cause is not removed, there may be fre- 
quently-recurring attacks, such as have been described, until a chronic 
diarrhea is finally established. 

Treatment. — The cases are usually and promptly cured if taken 
in time. Opium is the sovereign remedy; but before this is given a 
full dose of castor-oil should be administered. A teaspoonful may be 
given to an infant of from three to six months, a tablespoonful to a 
child over four years old. If the cause of the diarrhea is any mechan- 
ical irritation, this preliminary cathartic is an absolute necessity. It 
is a good rule in all cases. Calomel one-tenth to one-twentieth of a 
grain, or syrup of rhubarb (3j to 3jss) may be substituted for the 
oil; but they are less certain and less satisfactory. Five or six hours 
after the cathartic, the opium should be given. It is a good rule to 
prescribe a safe dose, and order it repeated after each stool. Paregoric 
and Dover's powders are probably as good as any, or subnitrate of 
bismuth and paregoric. For a child a year old, from six to ten drops 
of paregoric is a dose, or a quarter of a grain of Dover's powders may 
be ordered in the manner indicated. Opium stops peristalsis ; and 
after the intestines have been emptied, that is mainly what is wanted 
in these cases. 

In cases not yielding promptly to opium, bismuth subnitrate may 
be added. Keep the child quiet in the crib, and on no account must it 
be allowed to run about .till it is quite well. The diet must be boiled 
milk thickened with a little flour. Not much food should be given for 
from twelve to twenty hours, and then for three or four days only very 
easily-digested food which can almost entirely be absorbed. The intes- 
tines must be kept quiet until all irritation has subsided. Barley-water, 
thin broth, and whey may be used ; in many instances use no milk except 
breast milk. Careful feeding must be kept up for a week to prevent a 
recurrence of the diarrhea, If it is summer-time, this is imperative. 
A proper management of these cases of simple diarrhea is one of the 
most important prophylactic measures against severe forms of intes- 
tinal disease. On no account should these cases be neglected because 
the child happens to be teething. 






Diarrhea. 6 1 5 

CHOLERA INFANTUM., OR ACUTE DIARRHEA OF BACTERIAL ORIGIN. 

Synonyms. — Acute gastrointestinal catarrh, cholera infantum, 
summer complaint, summer diarrhea, infectious diarrhea. 

ACUTE DYSPEPTIC DIARRHEA. 

Etiology. — Acute dyspeptic diarrhea includes a greater number 
of cases of summer diarrhea, or at least forms a stage in these cases. 
It is said that it is most frequently the initial stage, but is sometimes 
the final one. The causes are summer heat, artificial feeding, bad 
habits of feeding, improper food, impure milk, bad surroundings, and 
city residence; all these are etiological factors. 

Pathology. — Dyspeptic diarrhea is a diarrhea set up by undigested 
foods in the intestines, and by the putrefactive changes in such food. 
If the resistance of the patient is great, the cause a transient one, and 
the case properly managed, there is only functional disorder, and there 
may be complete recovery in a few days. In a susceptible patient, 
where the exciting cause continues operative, or when improperly man- 
aged, the process continues, and anatomical changes are produced; the 
case then becomes one of gastro-entero-colitis, in which the dyspeptic 
diarrhea was the initial stage. 

Synonyms. — Acute gastro-intestinal catarrh, cholera infantum, 
gradual onset, with little or no fever, usually without any gastric dis- 
turbances ; secondly, a severe form, in which the onset is sudden, 
usually attended by high temperature and by vomiting. In the mild 
form there may be for the first few days no symptoms except the diar- 
rheal discharges, or the child may be peevish, fretful, especially so at 
night, and may seem generally out of sorts. From the fact that the 
general symptoms are so few, mothers often allow cases of this kind to 
go on for several days under the common belief that the children are 
"only teething." 

The stools are green or yellow,, thinner than normal, and contain- 
ing masses of undigested fat and occasionally curds. Sometimes they 
are of an offensive odor, but frequently not; there are usually from 
three to six passages daily. After a few days they contain in most 
cases mucus in smaller or larger quantities. Fruits or starch foods 
appear in the stools almost unchanged. The appetite may be normal, 
but is usually impaired, and may be almost lost after a few days. The 
tongue shows generally a, thin white coating; the mucous membrane 
of the mouth may be congested, or in very young infants covered with 
thrush. Sometimes the general health will not be noticeably affected 
for two or three weeks. Often after a few days the infant becomes 
pale and spiritless; it loses flesh, and its limbs become soft and flabby. 
If proper treatment is instituted, and the cause is removed, there is 
noticed an improvement in the character and frequency of the stools; 
the mucus disappears; the color becomes a pale yellowish green and 
finally yellow ; the appetite returns ; the strength and spirits improve ; 



6 1 6 Diarrhea. 

and the child recovers after an illness of from four to fourteen days. 
Relapses are very easily brought on by slight irregularities in diet, 
especially overfeeding. In the cases which do not run a favorable 
course, the disease may become either cholera infantum or enterocolitis. 
This change often takes place with great suddenness, and is frequently 
coincident with a few days of hot weather or follows some gross dietetic 
error. 

A third termination, but not as common as either of the preced- 
ing, is a continuance of the mild symptoms, with exacerbations and 
remissions, during the entire summer season, until the cold weather of 
autumn comes. 

x The cases may be cut off at any time by any incurrent disease, 
especially pneumonia. In the cases developing suddenly, the case is 
quite a different one. The attack may begin abruptly in a child appar- 
ently healthy, or there may have been for some days symptoms of slight 
intestinal derangement. If an infant, it is restless, cries much, sleeps 
but a few minutes at a time, and seems in distress. The skin is hot 
and dry, the temperature runs up rapidly to 102° or 103° Fahrenheit, 
often to 105° Fahrenheit; the abdomen is distended, and is hard; the 
]egs are usually drawn up, and all the symptoms indicate the <~nset of 
some grave disorder. The nervous symptoms in some cases are very 
severe, and even convulsions may occur. There may be great thirst so 
that everything offered is taken eagerly, or on the other hand everything 
may be refused. 

Usually in the course of from four to six hours after the onset the 
gastro-intestinal symptoms come on. There is first vomiting, which 
may be of undigested food taken many hours before. If this was milk, 
it frequently comes up in hard curds and very sour. After the stom- 
ach has been apparently emptied, mucus and serum are ejected in small 
quantities after much retching and straining, and sometimes the vomit- 
ing is bilious. The vomiting is easily excited by the giving of food or 
drink. Diarrhea soon follows, — first, feculent stools, then great bursts 
of flatus, with the expulsion of very thin yellowish stools of a terribly 
offensive odor. Four or five such discharges may occur in as many 
hours. In other cases the stools are gray or greenish yellow, some- 
times brown. But the characteristic features are the amount of gas 
expelled, the colicky pains preceding the discharges, and the sicken- 
ing odor. 

In a larger number of the cases this free evacuation of the bowels 
is followed by a fall of temperature and subsidence of the nervous 
symptoms, and the child falls asleep, to be awakened for an occasional 
stool after a few hours. 

The prostration is often great in the beginning, but not of long 
duration. Under favorable circumstances and with proper manage- 
ment, the case, after twenty-four or thirty-six hours of severe symp- 
toms, may go on to a rapid convalescence. The movements continue 



Diarrhea. 617 

abnormally frequent for three or four days, but gradually assume their 
normal character, and a prompt recovery can usually be expected. 

The chief features contributing to such favorable results are a 
good constitution on the part of the child, and the ability to regulate the 
feeding afterwards. 

If circumstances are not so favorable, if the child is cachetic and 
badly cared for, the fall in the temperature is often only a temporary 
one. The vomiting may not recur, but the diarrhea keeps up; the 
stools, gradually changing in character, become less offensive perhaps, 
and not so fluid, but they contain mucus, and are occasionally streaked 
with blood. In other words, they become more and more of the char- 
acter seen in enterocolitis. 

The general symptoms follow the same course ; the first profound 
impression made upon the nervous system subsides, and the child 
becomes pale, worn, prostrated. 

It may not be until the third or fourth attack that the entero- 
colitis is finally established. In children over two years old there are 
some features which differ from the cases described above as occurring 
in infants. 

Here the attack usually follows the ingestion of some indigestible 
food, such as green apples, unripe berries, etc., or milk which has been 
tainted from exposure. Vomiting does not come on so readily as in 
infants, pain is a much more prominent feature, and, as a rule, the tem- 
perature is lower. 

Such cases, although beginning with severe symptoms, usually 
make good recoveries ; there is much less likelihood of their running 
on to inflammatory forms of diarrheal disease than in the case of 
infants. 

Diagnosis. — The diagnostic points about the acute attacks are their 
sudden onset, their severe symptoms, their brief duration, and usually 
their favorable termination. They are violent, often alarming, but a 
brief convalescence is established in two or three days. 

Dyspeptic diarrhea is to be differentiated from cholera infantum 
and gastro-enteritis or enterocolitis, and in its onset from the general 
diseases, malaria, scarlatina, pneumonia, and tonsillitis. 

From cholera infantum it is distinguished by its milder char- 
acter, — the prostration being less, the temperature usually lower, the 
nervous symptoms less pronounced, — but particularly by the stools. 
The large serous neutral or alkaline stools belong only to cholera 
infantum. Although nearly every case of cholera infantum is pre- 
ceded by a dyspeptic diarrhea of greater or less severity, the former is 
not to be regarded as simply a more severe form of acute dyspeptic 
diarrhea. 

To differentiate the cases from those of inflammatory diarrhea is 
impossible for a day or two. The onset is often exactly the same, and 
we can not say at once whether they are going on to the development 



618 Diarrhea. 

of inflammatory changes or not. The subsidence of fever and all severe 
symptoms at the end of twenty-four hours or thirty-six hours shows that 
we have had only a putrefactive process with functional derangements, 
while a continuance of severe symptoms, and especially of the fever, 
beyond the second day, is usually evidence of inflammatory changes. 

The sudden development of high fever, prostration, vomiting, and 
even diarrhea, is common to very many diseases of infancy, especially 
to malaria, pneumonia, scarlatina, and tonsillitis. The symptoms of 
the latter are often so severe that it is not to be believed that the sole 
cause is a gastro-intestinal disorder. 

Tonsillitis is revealed by an inspection of the throat, and in scar- 
latina we must wait until the time for the rash. The question of 
malaria is a difficult one to decide, and may require an observation of 
the temperature for two or three days. 

Prognosis. — There are a very few cases of acute dyspeptic diar- 
rhea that prove fatal except among children already suffering from 
athrepsia. It is not uncommon among such children in institutions to 
have fatal cases of diarrhea which have never presented any choleraic 
symptoms, and which do not show at autopsy the lesions of entero- 
colitis. (W. Pepper, M. D., LL. D.) The feeble constitution is over- 
come in the first stages of intoxication and prostration. It is a sur- 
prise to see with how few symptoms such children succumb. 

Treatment of Dyspeptic Diarrhea. — Could proper prophylactic 
rules be carried out, these diseases would cease to be what they are 
now, — the greatest scourge of infancy. 

Prophylaxis means the hygienic surroundings of children and all 
sanitary conditions in the cities, cleaner streets, more open parks, and 
better sewerage. While these are not strictly filth diseases, yet filth 
certainly conduces to their development. In the tenement homes and 
institutions for infants there should be more air and sunlight, and less 
crowding, and about the country villages and in country homes greater 
cleanliness. Where there is no drainage only into cesspools, plenty 
of lime should be used daily during the summer especially; put lime 
about the dooryard where is thrown the waste water, etc. Keep the 
swill receptacle cleaned out. In country places we see swill sometimes 
accumulated in barrels and allowed to stand and ferment, sending off its 
poisonous germs, which, if inhaled by many persons or infants, will 
breed sickness. Frequent bathing and proper care of diapers will pre- 
vent sickness; the proper disinfecting of the stools where they are 
passed into a vessel by older children is as essential as it is in typhoid 
fever. (See Typhoid Fever.) 

Do not keep the young infant too warm ; seek as cool a place as pos- 
sible during the summer months. 

Feeding. — No weaning should be done, if it can be avoided, dur- 
ing summer. 

Too Frequent Feeding. — No more pernicious habit exists, and 
none more certain to set up gastro-intestinal disorders, than that of fill- 



Diarrhea. 619 

ing a large bottle with food, and putting the nipple into the child's 
mouth while lying in the crib, allowing it to sleep and eat alternately 
for the greater part of the time. The same can be said of the habit of 
allowing an infant to sleep at the mother's breast, and nurse every time 
it awakens during the night. 

Improper Food. — The habitual use of improper articles of food 
is a very important predisposing cause of diarrheal disease. Children 
thus fed suffer almost always from a mild intestinal catarrh. No 
infants' food can compare with cow's milk for infants during the first 
year of life. The extensive use of all dextrine and starchy foods as sub- 
stitutes during this period is to be deprecated, also during the second 
year of life the use of most vegetables, particularly beets, tomatoes, 
and potatoes, fruits especially in cities, and in the summer, all dried 
fruits, all cakes and sweets, coffee and tea. In older children improper 
food is the exciting cause in many cases. 

The care of bottles and rubber nipples is second in importance 
only to that of the milk itself. 

To Clean the Bottle. — Rinse with cold water, carefully scrub with 
brush and hot soap-suds, fill with weak soda solution, and let stand till 
needed for milk supply ; then boil for half an hour, or bake for half an 
hour in a hot oven, and fill with cotton. 

Never use long rubber tubes for feeding. Only rubber nipples, 
which slip over the mouth of the bottles, should be used. These should 
be turned inside out and scrubbed at least once a day, and at all times 
when not in use should be kept in a solution of borax or salicylate of 
sodium. 

Another important point in the prophylaxis of severe forms of dis- 
ease is early and prompt attention to all the milder derangements of 
the stomach and intestines, particularly during the summer. The 
larger proportion of cases of cholera infantum and enterocolitis are pre- 
ceded for some time by milder symptoms. Prompt attention at the 
onset is usually effectual. Too much can not be said in condemnation 
of the practise of allowing a slight looseness of the bowels to go on for 
a week or two simply because the child happens to be teething. Such 
an error has cost many an infant's life. 

Every gastro-intestinal derangement, no matter how slight, should 
receive prompt attention with the idea that at any time severe and even 
dangerous symptoms may supervene. Carefully sterilize the milk, 
observe scrupulous cleanliness in bottle and nipple, and give prompt 
attention to all mild derangements, especially in summer. Cut down 
the amount of food, and increase the amount of water during the days 
of excessive summer heat. Hygienic treatment — a change of air from 
the city to the seaside or to the mountains if the proper food can be 
obtained — is beneficial, or go to some place you will be likely to have 
the best food. In the country or in small towns a change is not so 
necessary, and in fact is not generally required unless the conditions 
become somewhat chronic. In such cases a change of air does more 



620 Diarrhea. 

good than all other means. Fresh air is of the utmost importance in 
all diarrheal cases in summer. Children should not be allowed to walk, 
even if they are old enough and strong enough to do so; they can be 
kept out in carriages or hammocks. Quiet is also very important. 

Clothing in summer should be the lightest flannel to be obtained ; 
a single loose garment is preferable. A thin layer of muslin can be 
put next the skin where there is much perspiration. 

Bathing. — Bathing is of very great advantage, to allay restlessness, 
as well as for cleanliness and the reduction of temperature. For the 
first purpose a sponge bath of alcohol and water or vinegar and water is 
sufficient ; for reduction of temperature only the tub-bath is to be relied 
upon. If the temperature continues above 102° Fahrenheit, or near 
that point, systematic bathing must be carried on. The temperature of 
the bath should be nearly 100° Fahrenheit when the child is put into it, 
and should then be gradually reduced to 80° or 85° by adding ice or cold 
water. The bath should be continued for from ten to thirty minutes, 
according to the amount of reduction effected, and repeated from two 
to eight times daily, according to the requirements of the case. 

The bath thus used has generally a very quieting effect, which 
would be entirely lost by the terror and excitement caused by putting 
an infant suddenly into a cold bath. Napkins should be removed from 
the child immediately after being soiled, and put into an antiseptic 
solution ; never leave a soiled napkin in the sick-room. Frequent wash- 
ing of the buttocks and genitals, together with the irritation from the 
discharges, often causes excoriations ; if these exist, use bran-water for 
bathing instead of plain water. 

Dietetic Treatment. — Dietetic and hygienic treatment in this class 
of diarrhea is very much more important than the use of drugs ; it is 
important to remember that during the acute stage of the febrile 
symptoms digestion is practically arrested. To give food requiring 
much digestion can do only harm in the stomach ; it produces 
irritation until it is expelled by vomiting, or passes into the intestines, 
adding to the fermenting masses there present and aggravating the 
existing disorder. In nursing infants the breast must be withheld as 
long as a disposition to vomit continues, and no food whatever given 
for six or eight or twelve hours. Thirst may be allayed by rice, barley, 
or toast water, or mineral water given cold and frequently but in minute 
quantities ; stimulants may be added to these if they are refused or 
vomited. Absolute rest of the stomach will do more than all else to 
hasten recovery. After the stomach has been quiet for ten or twelve 
hours, it is safe to allow the child to be put to the breast tentatively. 
The intervals of nursing should not be shorter than three hours, and 
the amount allowed at one feeding should not be more than one-half 
or one-third the usual meal. The remainder may be made up by 
mutton or chicken broth or by thin barley gruel. The amount may be 
steadily increased, so that in three or four days the breast may be taken 
exclusively. If there is any reason to suspect the cause of the attack 



Diarrhea. 621 

to be menstruation, pregnancy, or some nervous influence, as exhaus- 
tion, grief, or fright on the part of the nurse, the nursing from the 
breast must be stopped temporarily or permanently, according to cir- 
cumstances, and a wet-nurse secured, or begin hand feeding. 

In young infants who are being hand-fed, if the attack is a severe 
one in summer, a wet-nurse should be secured wherever this is possible. 
In cases where a wet-nurse is out of the question, we are brought face 
to face with one of the most difficult problems in the management of 
diarrhea; but until the exact nature of these dyspeptic diarrheas is 
better understood, we must be guided by experience alone. 

First, as to the use of cow's milk while nursing: Infants should 
generally be put back to the breast as soon as vomiting is permanently 
controlled, but it will not do to follow this rule in respect to cow's milk: 
this must generally be withheld in all forms until acute symptoms are 
past. The experience of the profession is nearly unanimous upon this 
point. (W. Pepper, M. D., LL. D.) Our reliance at this stage is 
upon egg water; 1 animal broths, 2 — chicken, mutton, or beef; the 
expressed juice of beefsteak or beef peptonoids ; 3 barley and rice water, 
and dextrine foods, such as Liebig or Horlick's malted milk, or Mellin's 
Food made without milk; flour-ball 4 and water, or wine whey. 5 

After the first two or three days, when the symptoms of acute 
fermentation have subsided and the stools are less frequent, we may 
add cow's milk to the diet tentatively. It is not enough that milk be 
sterilized, for this procedure, although of great value as a prophylactic 
measure, has but little curative value. 

There are three methods of administering milk. The first is by 
free dilution, — at least four parts of plain water or barley water to one 
of milk. In many cases this will agree perfectly, and nothing more 
will be required ; and as the case progresses, the proportion of milk can 
gradually be increased. The second is partial peptonization by the 
use of Fairchild's tubes. Directions for the preparation of the milk 
come wrapped around the tubes ; the process is to be continued from six 

l Egg Water. — Beat a little; to the white of one fresh egg add a teaspoonful of 
brandy and one pint of cold water, previously boiled. 

'^Animal Broth. — One pound of finely-chopped lean meat (chicken, mutton, or 
beef), one pint of cold water (one and one-half pints for young infant); put in a glass 
jar and let it stand from four to six hours on ice (or if in the country where no ice is to 
be had, put the jar into cold water), and keep covered. Cook three hours in a closed jar 
over a slow fire; strain, cool, skim off fat if any arises, season with salt, and feed warm or 
cold. It may be cleared with the white of an" egg if desired. 

3 Beef Juice. — Thick steak, broiled rare, juice pressed out with squeezer, and sea- 
soned. Of the beef peptonoids, Carnrick's liquid preparation is said to be best borne. 

^Flour-ball. — Tie two or three pounds of wheat flour in a bag and boil continu- 
ously for twelve hours; scrape off the outer shell, and grate the inner yellow portion 
(mainly dextrine) to make a thin gruel. • 

5 Wine Whey.— A teaspoonful of wine of pepsin; one pint of milk at a temperature 
of 110° to 120° Fahrenheit; let stand until firmly coagulated; break up curd and 
strain. Add sherry wine in proportion of one to four or one to six. Feed when cold. 



622 Diarrhea. 

to fifteen minutes, and not allowed to go so far as to develop the bitter 
taste. The third method is the same process continued for two hours, 
at the end of which time all the caseine has been digested. Lemon juice 
can now be added to cover up the bitter taste without causing any curd. 
With the addition of a little sugar, a very palatable food is thus pro- 
duced; and it is readily taken, all the more so because of the sour 
taste. 

Fermented milk, as koumiss, serves a very useful purpose, and can 
often be retained upon an irritable stomach when almost everything 
else is vomited. At first young infants will take it, but soon refuse it. 

General Rules Regarding Feeding. — No food whatever is to be 
given upon a very irritable stomach. Articles requiring the least diges- 
tion and leaving the smallest residue should next be tried. Food should 
be prescribed with the same exactness as for drugs. Quantity and fre- 
quency must be definitely stated, as well as the kind of food ordered. 
Directions should be made in writing, or they will be forgotten before 
the physician is out of the house. A jpraetical acquaintance with the 
proper appearance and taste of every food ordered is very necessary. 

There are four common mistakes in feeding in diarrhea, which 
are the cause of many failures, — feeding too much at a time, feeding too 
frequently, trying too many articles at once, and changing food before 
a thing has been really tested. 

For a single feeding the quantity allowed will vary according to 
the tolerance of the stomach ; but it should be always much less than 
is given in health, usually from one-fourth to one-half the amount, 
until the child demonstrates his capacity to digest more. It is rarely 
necessary to nurse or feed a sick child oftener than every two hours. 
Of course in cases of great prostration stimulants may be required much 
more frequently. We have only to imagine how an adult with a sick 
' stomach would feel to be offered something in the shape of food every 
five or ten minutes, in order to appreciate the disgust for all food 
which soon overtakes an infant who is similarly besieged. 

It is a difficult problem to feed these children under three years 
of age, capricious as they are by nature, and still more so by education ; 
and the judgment and tact of the physician are taxed to their utmost. 
We must have many resources; for a diet which one child takes well, 
the next child disdains utterly. The best method is to select from 
a list »f articles of accepted value (which has been mentioned in this 
article), such as circumstances will permit, and such as are most easily 
prepared properly, and try them patiently, one after another, until 
one is found which the child under treatment will take, and which 
agrees with it. 

Medical Treatment. — In these cases it must be borne in mind that 
we are not treating the intestinal inflammation, although such may be 
the ultimate result of the process beginning as a dyspeptic diarrhea. 
Essentially here our treatment is to be directed against the process of 



Diarrhea. 623 

fermentation or putrefaction, and toward the restoration of the normal 
gastro-intestinal functions, which have been deranged. 

The indications are, first, to evacuate the fermenting masses from 
the stomach and intestines; second, to combat the process of decompo- 
sition by drugs and proper food; third, to restore healthy action by 
intestinal hygiene ; fourth, to treat symptoms and complications. 

Emetics, although they may serve a very useful purpose in older 
children, are not to be advised in young infants. 

In such cases the most certain measures are to wash out the stom- 
ach, but this is to be done only in cases where there is uncontrollable 
vomiting. The largest-size flexible rubber catheter is the best instru- 
ment, and plain lukewarm water is considered best. The water is 
allowed to flow in and out freely until it comes away quite clear. 

Stomach washing may be practised without danger by the physician 
in the case of youngest infants. It is a simple procedure; in fact, it 
is easy to pass the tube into the oesophagus, as any one familiar with 
intubation will appreciate. A simple washing-out of the stomach in 
most cases is all that is required. It is never necessary to repeat it more 
than once daily. After the stomach has been emptied, a small quantity 
of some medicinal solution may be left in the organ if desired. In 
Germany the solution most employed is said to be a three per cent 
solution of benzoate of sodium. The author has found subnitrate of 
bismuth to be very useful in dyspepsia of bacterial origin in adults, 
after washing out the stomach. Usually ten grains are administered. 
In adult cases the author has had very satisfactory results by the use 
of the galvanic current, applied through the stomach tube direct to the 
mucous membrane of the stomach, water having been passed into the 
stomach previously, for the purpose of conducting the current evenly 
over the mucous membrane, etc. ( See article on Electricity. ) It will 
destroy the bacteria in the stomach. 

Returning now to the infant ; as a substitute for stomach washing, 
some authors have advocated the practise of allowing infants to drink 
freely of fluids, especially ice-water, which is generally taken readily, 
although almost immediately vomited. But it is unsatisfactory in its 
results, and certainly acts as an irritant to the stomach. Washing out 
the stomach is undoubtedly the best practise. 

To empty the intestines is necessary in every instance, no matter 
whether or not any indigestible food has been taken. This may be 
accomplished by cathartics or by intestinal irrigation. Of the cathar- 
tics, castor-oil and calomel are greatly superior to all others. Calomel 
has the advantage of ease of administration, its favorable effect upon 
vomiting, and its anti-fermentative effect, as well as its purgative action. 
One-tenth or sometimes one-fourth of a grain of the tablet triturates 
given dry upon the tongue is sufficient ; for a child under two years 
give every two hours till three doses are administered. If the stomach 
is not upset, castor-oil is all that is needed to sweep out the whole 
intestinal canal, carrying away all its pent-up, fermenting mass; it 



624 Diarrhea. 

causes little griping, but you may add a few drops of paregoric or not, 
according to circumstances, and the after effects are constipating. But 
if there is vomiting, first give the calomel, and follow, if need be, 
with a small dose of castor-oil in about twelve hours. A child a year 
old may take two teaspoonfuls of castor-oil with a few drops of r-lear 
brandy or in an emulsion, taken warm always. It is important that 
a full dose be given, the initial cathartic dose of castor-oil. Almost 
complete abstinence for twenty-four hours, and very careful feeding 
after that time, suffice to cure a very considerable proportion of these 
cases. Only cathartics can be employed to evacuate the small intes- 
tines, while for the colon we may use enemas by irrigation of the 
intestines. This has now been so long practised, both in this country 
and in Germany, that its value is well established. To be effectual, 
the water must reach the ileo-cascal valve ; it can not be expected to do 
more. Attention, to detail is necessary for success. The infant is 
placed upon the back, with hips elevated on a small pillow, and the 
water introduced through the largest size of a flexible rubber catheter 
or a rubber rectal tube of the same size, which is passed into the colon — 
if possible, beyond the sigmoid flexure, as in that case 'the intestines 
above are easily filled. At least eight inches should be introduced. 
The catheter is attached to the nozzle of a fountain syringe, the bag 
of which is held three or four feet above the patient. Daring the 
introduction the water should be allowed to flow; and as the intestines 
become distended a little in advance of the catheter, this greatly facili- 
tates the process. The passage of the water into the bowel high up is 
also aided by abdominal manipulation. To be certain that the water 
has reached to the caecum, we must have at least a pint in the colon 
at once for a child of six months, and a quart for a child two years old. 
(W. Pepper, M. D., LL. D.) The author has found two-thirds of a 
pint of warm water for an infant six to ten months old a sufficient 
amount to use in irrigation of the bowels, and usually one pint is 
enough for a child two or three years of age. In giving these enemas 
it is necessary to press the buttocks firmly together while the irriga- 
tion is going on, just so as not to press the catheter too hard, as this 
would stop the water from passing through it. A good plan is to put 
a roller bandage around the catheter until as thick as a small wrist, 
and press on this bandage against the anus, and it will aid the bowels 
in retaining the enema till the required amount of water is passed 
high up. Should the enema be retained too long, place the child on its 
feet and knead the bowels gently, and the water will soon be ejected. 
Irrigation need not be repeated oftener than once in twenty-four 
hours, never over twice ; they should be made by a physician or by a 
well- trained nurse. The object is to flush out the intestines well, as 
one would wash out an abscess thoroughly. The water may return 
through the tube or alongside of it. It will be found that water pre- 
viously boiled and cooled, with one dram of table salt added to a pint 
of boiled water, is less irritating ; also flaxseed tea is the most soothing 



Diarrhea. 625 

enema for irrigating the bowels. The author uses the flaxseed in pref- 
erence to the salt solution. If there is an abundant secretion of rather 
thick mucus, a solution of borax, one dram to the pint of boiled water, 
is very effective. 

The injection of astringent solutions is not called for in acute 
dyspeptic diarrhea. They are referred to under enterocolitis. The 
temperature of fluids for injection is a matter of choice by the physi- 
cian. The author uses a temperature of 70° or 80° Fahrenheit; others 
use cold or ice-water ; still others prefer lukewarm water. 

Antiseptic Drugs. — The drugs which can be relied upon to influ- 
ence decomposition in the lower ileum and the colon must be insoluble, 
and must be capable of being administered in large doses. Naphthaline 
and bismuth have this reputation. 

Naphthaline may be given in from two to four-grain doses hourly, 
either in suspension or rubbed up with sugar dry, and put upon the 
tongue ; give it according to the age of the child. Bismuth subnitrate 
is a favorite remedy for most physicians ; it is of great value outside 
the body, as we know, in restraining putrefaction. 

Bismuth is easy to administer, and is an astringent as well as con- 
taining antiseptic properties. Subnitrate of bismuth is best given in 
suspension in mucilage with a little spirits of chloroform or a little 
brandy. 

]£: Bismuth subnit gr. x 

Mucil. acacise 3j 

Spt. vini gall Ttj[ iii to v 

Misce. 
Sig. : This is one dose. (May sweeten to taste.) 

To be efficient, bismuth must be given in large doses ; that is, two 
to three drams daily to a child one or two years old. It always blackens 
the stools. ~No remedy in these cases has held its place so firmly as 
has bismuth. Calomel and salol are .antiseptics ; calomel has been men- 
tioned as to its antiseptic qualities aside from being a most effective 
cathartic. The tablet triturate is the best form in which to administer 
the calomel which has been referred to. A dose for an infant is from 
one-twelfth to one-sixth, as indicated, to be given every hour to a child 
a year or two years old, till the required amount is given, that is, till the 
passages become greenish or brownish. 

Gray powder may be used in the same way in half-grain doses 
with similar effect. 

Salol is of unquestioned value in these cases. It is best given in 
suspension in doses of one or two grains every two hours to an infant 
a year old, or to a child two years old. 

Salicylate of sodium has been most satisfactory in some authors' 
hands. It is to be given in doses of one or two grains every two hours 
to a child a year old. It should always be largely diluted ; it should be 
given with the white of an egg ; then it does not have any unpleasant 

40 



626 Diarrhea. 

effect upon the membranes of the stomach. Sweet milk is also most 
excellent to give it in, where the stomach can bear sterilized milk. 
Calcium salt is preferred by some writers. 

The bichloride of mercury has been very unsatisfactory in some- 
hands. 

A careful review of this whole subject from both a theoretical 
and a practical standpoint brings us to the conclusion that asepsis is 
better than antiseptics, asepsis being taken to include thorough cleans- 
ing of the canal, and the administration of foods free from germs and 
so selected as to be as completely absorbed as possible, leaving but a 
^small residue. To this must be added pure air in the sick-room. 

The acids have been recommended as antiseptics on account of 
their well-known power to check bacterial growth. The acids most 
widely used have been hydrochloric and lactic acid. Sulphuric acid is 
a favorite remedy with some physicians, prescribed as follows: — 

5: Acidi sulphurici aromatici f3ij 

Ext. hsematoxyli 3iii 

Syr. zingiberis f^iss 

Misce et adde : 

Tr-opii camphoratse , . , . . fgjss 

Sig. : Dessert-spoonful in water, every six hours. After the bowels 
are checked, diminish the amount of paregoric in the prescription, and 
add instead the same amount of ginger. 

Astringents. — Vegetable astringents are not in use for these dis- 
eases, as was the case formerly. They are considered positively harm- 
ful, as tannin, kino, catechu, etc. 

Mineral Astringents. — Bismuth, the favorite one, has been suffi- 
ciently spoken of in this article. 

As a general rule, in these diseases opium is contraindicated until 
the intestinal tract has been thoroughly cleaned out by cathartics or by 
irrigation. If the nurnber of discharges is small, or they are very 
offensive, opium is not indicated. Opium is especially to be avoided 
when marked cerebral symptoms and high temperature coexist with 
scanty discharges. It is indicated early in the disease, as soon as the 
canal has been thoroughly emptied of its putrefying contents ; and also 
in certain cases, which are quite common, where the administration of 
food is immediately followed by a movement of the bowels ; also where, 
without an elevation of temperature, and often with a good appetite, 
undigested foods, especially fat, constantly appears in the stools, which 
are frequent, because the intestinal contents are hurried along so rapidly 
that there is not sufficient time for complete digestion and absorption. 

As to the preparations, there is not much choice between paregoric 
and Dover's powder. It has to be prescribed in doses suited to the 
age, enough to control the excessive peristalsis. 

But opium should not be given to the degree of locking up the 
bowels entirely, or of causing marked drowsiness or stupor. For an 



Diarrhea. 627 

average child of one year, give eight to fifteen drops of the deodorized 
tincture, or one-fifth of a grain of Dover's powder, to be repeated every 
one, two, or four hours, the frequency being gauged according to the 
effect produced. Frequent use of minute doses is the best plan. 

If, following the use of opium and a consequent diminution in the 
number of the discharges, there is no improvement in their character, 
and a rise of temperature occurs, too much has been given, and the 
amount must be greatly reduced or the drug stopped altogether. 

Digestive Ferments. — Pepsin and pancreatin are valuable addi- 
tions. Predigested foods have already been spoken of. These fer- 
ments may be given in powder or scale form. The pepsin may be 
given immediately after feeding, and the pancreatin one hour after 
meals, with decided advantage. Fairchilds Brothers and Park, Davis 
& Co.'s preparations are the most popular. 

Stimulants are given with advantage in a very considerable pro- 
portion of the cases. The general condition of the patient is the best 
guide as to the time for stimulation and the amount to be given. Stim- 
ulants should be given more frequently, and earlier in the disease, than 
they are usually prescribed. Brandy is the best preparation for gen- 
eral use, champagne being preferred when there is much vomiting. An 
infant one year old will take with advantage an ounce of brandy, prop- 
erly diluted, in twenty-four hours. 

General Considerations in Treatment. — First, all cases must be 
carefully watched and seen frequently by the physician. Second, the 
character of the discharges is, in most cases, a better indication than 
is the number, of the condition of the patient and of the effect of rem- 
edies. Nothing is simpler than to give opium enough to reduce the 
number of passages ; but unless there is some other sign of improve- 
ment, one has probably done little good and may have done much harm. 
Third, every therapeutic measure must contribute to one end, viz., to 
the improvement of the patient's general condition. Fourth, no mat- 
ter how strongly we may be convinced of the value of any drug or com- 
bination of drugs, if these continue to disturb the stomach, they are 
worse than useless. Fifth, the use of all drugs is of very minor impor- 
tance as compared with proper diet and hygienic treatment. Sixth, 
great care is necessary in every case for two or three weeks after an 
attack, from the strong tendency of the disease to recur. 



CHAPTEE XLIX. 
CHOLERA INFANTUM!. 

In comparison with the frequency of the foregoing class of cases, 
those of cholera infantum are rare. They are said to include not over 
t^wo per cent of cases of summer diarrhea. 

The term should be restricted to cases of genuine choleriform diar- 
rhea. (See article on Cholera Infestasia.) Cholera infantum is almost 
never met with in children who are entirely breast-fed. It is never 
seen except in warm weather. 

Symptoms and Diagnosis. — Cholera infantum can scarcely be mis- 
taken for any other form of intestinal disease, if its chief symptoms are 
kept in mind. The constant vomiting, the profuse serous stools, the 
great thirst, dry tongue, high temperature, great restlessness, followed 
by rapidly-developing collapse, sunken fontanel, pinched, anxious face, 
cold extremities, weak pulse, dyspnoea, cyanosis, stupor, coma, convul- 
sions, and death, all occurring in the course of one or two days, are 
unmistakable. The only things with which the disease can be confused 
are acute gastro-enteritis and acute dyspeptic diarrhea. 

From the first it is distinguished by its shorter course, by the more 
intense nervous symptoms, and by the stools, which in cholera infantum 
are very thin, soon almost entirely watery and colorless ; in inflammatory 
diarrhea they are green or greenish yellow, contain mucus, and are not 
so large nor so frequent. 

In acute dyspeptic diarrhea we have, as in cholera infantum, the 
sudden development of quite severe symptoms, with vomiting and diar- 
rhea, but both are less in degree. The temperature is not often so 
high, and it usually falls when the canal has been freely emptied. The 
stools contain undigested food, much gas, and are very foul; but we 
have the pure serous stools ; the prostration and all the nervous symp- 
toms are very much less, and the disease very rarely proves fatal. 

Prognosis. — The prognosis is worse in a young infant, worse for 
one who has been badly fed and poorly cared for, worse when all the 
surroundings are unfavorable, worse when the patient has suffered from 
previous intestinal diseases, and worse in midsummer. 

The symptoms indicating a bad prognosis are very high temper- 
ature, 106° to 108° Fahrenheit, profound nervous depression, and 
uncontrollable vomiting. Favorable symptoms are cessation of the 
vomiting, a falling temperature (but not subnormal), quiet sleep, and 
improvement in the pulse and cutaneous circulation. ]STo cases should 
ever be despaired of. 

(628) 



Cholera Infantum. 629 

Treatment. — In the way of prophylaxis much can be done. All 
the general rules of prevention laid down in this article under bacterial 
diarrhea apply the same to cholera infantum. (See Prophylaxis.) 
Special emphasis, however, is to be laid upon the early treatment of the 
milder intestinal derangements, since it is a rule to which the excep- 
tions are few, that such symptoms precede for some days the occurrence 
of the choleriform diarrhea. 

No cases of dyspeptic diarrhea are to be neglected in the summer 
on the score of an existing dentition. Every and all looseness of the 
bowels during the summer season needs careful watching; early treat- 
ment must be resorted to, with the idea that at any time a sudden 
development of dangerous symptoms might occur. 

The same remarks apply also to convalescence after the entero- 
colitis. Vigilance should not be relaxed for a day until the stools are 
normal, so often does one see cases which have been progressing, so 
far as it is possible to judge, steadily towards recovery, cut off in a day 
by the development of cholera infantum. 

The main indications to be met in cholera infantum are: First, 
to arrest the discharges; second, to strengthen the heart and sustain the 
system; third, to reduce the temperature; fourth, to allay nervous 
symptoms. 

Nothing in my hands has proved so generally useful as the hypo- 
dermic use of morphine in combination with atropine. It must be 
used with great caution, as it is capable of doing much harm. 

The special symptoms indicating opium are very abundant vomit- 
ing and purging, nervous excitement, restlessness, delirium or convul- 
sions, and feeble pulse. Opium is contraindicated where the purging; 
has ceased or is slight, and where there is drowsiness, stupor, or relaxa- 
tion. The effect must always be carefully watched ; it is better to give 
small doses and repeated rather than a large initial dose. It may be 
repeated in an hour unless the desired effects are produced, which is 
the arrest of the vomiting and purging, or at least a great diminution 
of them, with improved heart's action, and the nervous symptoms 
allayed. 

Here, as in shock, we find morphine our most reliable heart stim- 
ulant. 

Opium given by the mouth is not to be relied on: there is too 
much uncertainty as to its absorption. It should be given hypo- 
dermically. 

In the treatment of the high temperature, it is said that all drugs 
are useless. The child should be put in a tub-bath at a temperature 
of 100° Fahrenheit to avoid shock and fright, and the temperature of 
the bath gradually lowered by adding ice till 85° or 88° Fahrenheit is 
reached. This may be kept up for from ten to thirty minutes, accord- 
ing to the amount of reduction in the temperature effected. Baths to 
be efficient must be used every hour or every two hours, if symptoms 
are threatening. Iced cloths or an ice-cap should be kept applied to 



630 Cholera Infantum. 

the head. Ice-water injections are a valuable accessory to the treat- 
ment of baths. A rectal tube should be used, and the injection carried 
high up into the colon, the water being allowed to now in and out freely. 

The only things to be allowed by the mouth are champagne and 
brandy and ice. Out in the country ice can not always be obtained. 
In this case use cold well-water with a little brandy, which must be 
given in minute quantities every few minutes. Stimulants may have 
to be used hypodermically when the stomach will not retain anything. 

Either brandy or ether may be used freely at short intervals. To 
attempt to give, by the mouth, food, or astringents, or drugs of any kind, 
ig often worse than useless. 

After vomiting has stopped, and the purging is under control, 
nourishment in very small quantities may be tried. For an infant 
breast milk should be obtained if possible. Cow's milk must be com- 
pletely peptonized before giving it to the child. Whey or koumiss may 
be given. They will usually take it eagerly, on account of thirst ; beef 
or chicken broth may be tried for older children. Only give a teaspoon- 
f ul at a time to see if it is well borne ; give in small quantities every half 
hour ; the quantity must be cautiously increased, and the food given at 
longer intervals. It must be remembered that no digestion is going 
on during the acute stage, hence there can not be much absorption of 
food taken into the stomach. If the case goes favorably, the subse- 
quent feeding must be carried out the same as prescribed under the 
head of dyspeptic diarrhea. After the stage of violent diarrhea and 
vomiting has passed, and if the hydrocephaloid symptoms are present, 
the case is to be managed according to its symptoms. Opium is to be 
avoided ; stimulants by the mouth are to be used freely where they can 
be retained, and where not, must be given hypodermically. If there are 
cold extremities and subnormal temperature, hot mustard baths should 
be used to establish reaction, sinapisms applied freely all over the body, 
and hot-water bags or bottles used all about the patient. Baginsky 
recommends hot-water rectal injections. Camphor is sometimes a use- 
ful stimulant. 

Hygienic treatment during convalescence is all-important. If the 
patient survives the first violent stage, he should be removed as soon as 
possible, either from the city to the seaside or out to the mountains. 
A change of air is the important thing. 

A continuance of the fever and diarrhea without the extreme 
nervous symptoms and after the vomiting has subsided, means usually 
that the case has become one of enterocolitis ; it is then to be managed 
like such cases, beginning without the choleraic symptoms. 

ACUTE ENTEROCOLITIS. 

The term acute enterocolitis is used here as a so-called clinical 
one, to embrace all forms of acute diarrheal disease with inflammatory 
conditions or lesions. It may occur at any time of the year, but is 
more common in the warm season. 



Cholera Infantum. b31 

Cold has long been regarded as a prominent factor, though this is 
regarded by some as an open question. 

Symptoms. — There are three quite distinct forms met with : First, 
the dysenteric form, which is primary; secondly, the more common 
acute variety, which usually begins as an acute dyspeptic diarrhea, or 
follows cholera infantum ; thirdly, a subacute variety, which, it is said, 
may follow either of the foregoing. 

The Dysenteric Form. — These cases constitute but a small pro- 
portion of the class. They are more common in older infants than 
during the first eight months. The onset is sometimes quite abrupt, 
and sometimes gradual. In the abrupt cases we have often severe 
constitutional symptoms, the temperature rising to 104° or 105° 
Fahrenheit, prostration, not often vomiting, but severe nervous dis- 
turbance, frequently delirium, rarely convulsions. In case of gradual 
onset, which is most common, the temperature is scarcely elevated at all, 
and the symptoms are almost entirely those of an intestinal character. 
After one or two fsecal stools, the discharges consist of almost pure mu- 
cus or mucus streaked with blood, more rarely blood in clots. There is 
usually but little odor to these stools, but sometimes it is very marked. 
They are frequent, often every half hour, and proportionally small, 
sometimes only about a teaspoonful being found on the napkin after 
severe straining efforts. There are almost constant tenesmus and grip- 
ing in severe cases. Prolapsus ani is a frequent complication, and 
sometimes a very troublesome one. As the case goes on, the passages 
contain more or less undigested food, and usually lose their peculiar 
character or have it only occasionally. 

In severe cases there may be very great prostration, rapid wasting, 
and death, from exhaustion or from complications, in a week. More 
often they assume after a time the symptoms of an ordinary entero- 
colitis, and run a slow, indefinite course, with a tendency to frequent 
relapses. 

The Acute Form. — Much more numerous than the foregoing are 
the cases of enterocolitis which follow an acute dyspeptic diarrhea or 
cholera infantum. When the latter, we have a cessation of the vomit- 
ing and serous discharges, with a fall in the temperature, and many of 
the profound nervous symptoms pass off; the stools become more con- 
sistent, of a brown, gray, or greenish color, contain large quantities of 
mucus and undigested food, and are more or less offensive. Some 
appetite returns, the symptoms of shock which characterize the cholera- 
infantum stage pass away, and the pulse improves; but there are con- 
tinued loss of flesh, some fever, usually a temperature 101° to 102° 
Fahrenheit, restlessness, peevishness, etc. These symptoms may last 
for two or three weeks, with exacerbations and remissions. 

High fever in these cases is not common; but when it occurs, it 
usually betokens an early fatal termination. 

Complications* at any time may cause a rise in temperature. 



632 Cholera Infantum. 

The pulse is always increased in frequency; the character of the 
pulse should always be noted. In bad cases it is feeble, irregular, or 
intermittent. The capillary circulation is poor, and the extremities 
are often cold, even when the rectal temperature is elevated. 

Nervous Symptoms. — These are great restlessness, constant crying 
from thirst or pain, rolling in the crib, biting at the fingers, scratching 
the face, etc. The latter symptoms may be of an opposite character in 
an infant ; there may be general relaxation, dulness, and the child may 
lie sometimes for hours unless disturbed. 

Mouth and Tongue. — During the early stage the tongue is usually 
coated heavily and is moist ; later, it is often dry, red, and glazed ; the 
lips crack and bleed readily. 

Vomiting. — Vomiting does not depend upon enterocolitis; it 
depends upon coexisting gastritis. Persistent vomiting developing in 
the course of enterocolitis is always a bad sign, and means often the 
supervening of cholera infantum, and speedy dissolution. Single 
attacks of vomiting are due to dietetic errors. 

Stools. — The small mucous passages streaked with blood may be 
from fifteen to thirty daily. The larger ones usually average from four 
to ten daily. 

Diminution in the number of discharges is not always a sign of 
improvement; if this is accompanied by a rising temperature and 
increasing nervous symptoms, it is a bad sign. The stools sometimes 
entirely cease for from twelve to twenty-four hours before death, due 
probably to paralysis of the muscular coat of the bowels. The abdomen 
may be hard and distended during the early stage ; at other times it is 
natural or retracted and soft. 

The appetite in most cases is impaired; and it may be completely 
lost. 

The urine is nearly always diminished in quantity and high- 
colored and frequently is loaded with urates. 

Subacute Cases. — After acute symptoms which have been de- 
scribed, have lasted for a variable time, — from two to four weeks, — 
and have passed away, the fever quite ceases, the stomach is quiet, food 
is readily taken, the nervous symptoms abate ; but sometimes the diar- 
rhea continues, there is no improvement in nutrition, and there is 
cachexia with extreme anaemia. The stools are not frequent in these 
cases, only four or five daily, but they contain a large amount of mucus 
and undigested food, and are often of a very bad odor. They may 
improve for a day or two upon a change of diet or medical treatment, 
but soon return to the old condition. After such symptoms have lasted 
Hve or six weeks, there is a gradual improvement in the stools and in 
weight, and the patient enters upon a slow convalescence, which is often 
interrupted by relapses, and the case becomes one of chronic diarrhea. 

Acute Catarrhal Variety. — The very severe cases of this class 
resemble in all respects those of croupous inflammation. They are 



Cholera Infantum. 633 

rare, are characterized by a high temperature, which runs from 102° 
to 105° Fahrenheit, and blood in the stools is a frequent feature and 
sometimes comes in large amounts. They are rapid in their course, 
with intense symptoms, continuous high temperature, prostration, etc. 
The shorter course lasts about three days. Most cases are fatal. In 
the milder variety the temperature ranges from 101° to 103° Fahren- 
heit. The symptoms subside after a week or ten days, and are suc- 
ceeded by a mild intestinal derangement for two or three weeks more. 
Relapses are common, and convalescence slow. 

Follicular Ulceration. — If a delicate infant that from time to 
time has been specially prone to diarrheal attacks, especially if it has 
had symptoms of mild catarrh of the colon, has an attack which starts 
in with green mucous stools, and which continues with unabated severity 
for a week or ten days, with low fever, acute follicular inflammation is 
very certain, and ulceration is probable. If these symptoms continue 
for three weeks without intermission, the child all the time failing 
steadily in strength, the diagnosis of follicular ulcers becomes almost 
a certainty. If, on the contrary, after three or four days of acute 
symptoms there is improvement in the stools, and occasionally one quite 
faecal in character, and if after a few days another such exacerbation 
occurs, succeeded by another remission, and so on, we may be pretty 
sure that no ulcers have yet formed. If follicular ulcers have formed, 
the patient rarely recovers. 

Complications. — During the early acute stage of entero-colitis, an 
intense erythema frequently develops about the anus, nates, and geni- 
tals ; in severe cases the thighs, loins, and legs also are involved. 
Thrush may develop in the mouth of an infant. 

Diagnosis. — The symptoms have been sufficiently described in the 
foregoing; and the differential diagnosis of entero-colitis from cholera 
infantum and acute dyspeptic diarrhea, have already been discussed under 
these diseases. In older children the difficulty is often a very real one. 
Typhoid fever is usually distinguished by its more constant fever, the 
enlargement of the spleen, the tympanitic distention of the abdomen, 
and most of all by the eruption. The fact of an epidemic prevailing 
is also to be considered. The dysenteric form of colitis may be con- 
founded with intussusception, which should not be lost sight of. Yet 
the records of cases of intussusception show that in the beginning a 
very large proportion of them had been regarded as cases of dysentery. 
In intussusception we have a very sudden onset — often the hour can 
be definitely stated by the mother — there are acute pain and tenesmus, 
followed by bloody and mucous passages. In intussusception the 
amount of blood is often quite large, as much as a tablespoonful of clear 
blood. There is vomiting — often persistent — with very marked pros- 
tration, but no fever. The later symptoms are absolute stoppage of 
the bowels, abdominal tumor, tympanitis, rising temperature, collapse, 



634 Cholera Infantum. 

and stercoraceous vomiting, and have nothing in common with dysen- 
teric colitis. 

Prognosis. — In making a prognosis, the child's constitution, its 
surroundings, the ability of the parent to carry out the proper line of 
treatment, the duration of symptoms at the time the case comes under 
the treatment, the part of the summer in which the attack occurs, and 
the existence of complications should all be taken into consideration. 
The prognosis is worse in a feeble or cachectic child, or in one suffer- 
ing from rickets, or with inherited tubercular tendencies. It is worse 
in cities among the poorer classes, and in institutions. It is worse in 
children who have previously been badly fed, in those who have suf- 
fered earlier in the season from diarrheal attacks, and those who have 
recently been weaned. In these cases there are continued elevation of 
temperature, vomiting, rapid wasting, and continuous severe nervous 
symptoms. 

Treatment. — Prophylaxis involves all that has been said (which 
see). It includes special care, and early and prompt treatment of all 
the milder forms of diarrhea before the process shall have gone on to 
form more serious lesions. 

Hygienic treatment must be carried out here as well as in all 
other dyspeptic diarrheas. Change of air from the city is often most 
imperative, the seashore being considered preferable. 

Fresh, pure air, and plenty of it, is a necessity for all cases. 
The same directions for bathing may be followed as described under 
Acute Dyspeptic Diarrhea. Great care must always be taken to 
see that children are warmly covered at night. 

Dietetic Treatment. — In the early stages, if the stomach is affected 
the case is to be managed as one of acute dyspeptic diarrhea. The gas- 
tric symptoms will usually have subsided at the end of two days, and 
we have then only the intestinal ones to deal with. 

If an infant is nursing and the breast milk is healthy, it is not 
necessary to withdraw the infant from the breast. If it is only a few 
months old, and has been hand-fed from the beginning, or just weaned, 
its life may depend on its having a wet-nurse. If it is an impossibility 
to secure a wet-nurse, we should begin with barley, rice, or arrowroot 
water, or thin mutton or chicken broth, and come back gradually to cow's 
milk. The milk should be peptonized for two hours, then diluted with 
four or five times its bulk of gruel made from "flour-ball" (as has been 
described under the head of Dyspeptic Diarrhea), or barley flour, or 
rice. If curds or fat masses appear at once in the stools on the addi- 
tion of the milk, it must be stopped and the white-of-egg mixture sub- 
stituted, or some of the prepared foods, Liebig's, Horlick's, or Mellin's, 
may be tried without milk. 

The greatest care should be taken to see that the milk is the best 
that can be obtained, and it must be sterilized, or at least boiled and 
kept on ice, never in a room nor out of the window, as the bad air 



Cholera Infantum. 635 

passes out of the room through the open window, and this is bad for 
the milk. Milk which turns the blue litmus paper quickly should not 
be used, although this is not a test to be relied upon. 

Raw scraped beef put through a sieve and rolled into little balls 
with salt or sugar to season is sometimes a very valuable resource. 
Two or three teaspoonfuls of the meat may be given daily; but if the 
meat appears in the stools undigested, we must stop its use. The dan- 
ger of overfeeding must be guarded against as well as that of giving 
too little nourishment. One's judgment must be used as to the amount 
required for the child, taking the age into consideration. An exact 
record should always be kept of just how much the child does take, and 
the doctor may find that a child six months of age, who ought to get 
in bulk from twenty-four to thirty ounces in twenty-four hours, is get- 
ting only eight or ten. Children should be fed regularly, not oftener 
than every two hours. It is always important that foods giving as lit- 
tle residue as possible be chosen, so as to leave as little as possible to 
cause irritation and decomposition in the lower intestines. In older 
children, the milk diet, or diet of milk and gruel, or wheat or barley 
flour, alternating with mutton broth, usually succeeds best. 

Special care should be given to the diet during convalescence. 
Relapses from improper feeding come on very rapidly. A single 
peach, we see it reported, will cause a relapse, and a few raisins, a 
fatal one. 

The general rules laid down for dyspeptic diarrhea must be used 
in acute enterocolitis. 

Medical Treatment. — In the early stages the case is to be man- 
aged as one of acute dyspeptic diarrhea, by evacuants, antiseptics, and 
the judicious use of opium. It is of the first importance now that 
nothing should be done to disturb the stomach or the powers of diges- 
tion, which are always impaired to a greater or lesser degree. Hence 
overdosing must be guarded against. 

From time to time we may aid the stomach by the use of pepsin, 
hydrochloric acid, pancreatin, and alkalies, or either lime-water or 
magnesia added to the food. The progress of the lesions in the bowels 
depends very much upon how well we can nurse feeble powers of diges- 
tion and absorption. By the above measures we hope to influence the 
intestines indirectly. Antiseptics are here of much less value than in 
cases of acute dyspeptic diarrhea. Calomel is said to do but little 
good, except in the acute exacerbations which come on from time to 
time. The salts of salicylic acid, both the sodium and calcium salts, 
and salol, may be given as previously directed. Bismuth subnitrate 
does not have much good effect,, and vegetable astringents are useless. 
Opium is of value in these cases, but must be used with great discre- 
tion. It is particularly indicated when the stools are thin, frequent, 
of a not very offensive character, and when they are excited by the 
ingestion of food. It is to be used with great caution when the stools 
are small, infrequent, and very foul, and also when there are marked 



636 Cholera Infantum. 

nervous symptoms. It is best administered in a separate prescription 
and used occasionally for a specific effect. (See the use of opium in 
acute dyspeptic diarrhea and use it the same for acute enterocolitis.) 
The old-fashioned emulsion of castor-oil is beneficial in a great 
many cases. The following is a good formula: — 

\y. Olei ricini, 

Spt. vini gall, aa flavin 

Mucil. acacise, 

Aqua dest, aa 3ss 

Misce. 
^ Sig. : One dose for a child of twelve to eighteen months ; repeated 
every two or four hours. 

In these cases, and in some others where there is much colicky 
pain and tenderness of the abdomen, with stools streaked with blood, 
much benefit is derived from thin flaxseed poultices applied to the 
abdomen, or from mild counter-irritation by turpentine stupes or by 
mustard. 

Stimulants are needed in almost all cases. Even in young infants 
there is no valid objection. If the use of alcohol is ever justifiable in 
medicine, it is in these cases of intestinal inflammation, where we have 
extreme prostration, feeble powers of digestion and assimilation, and 
often a great repugnance to food of every kind. Stimulants are needed 
in the early stages as soon as the pulse becomes weak and the capil- 
lary circulation poor. At this time, old brandy is the best preparation 
for most cases. Blackberry brandy is preferred by many, and should 
be given well diluted. As much as thirty drops every hour can be 
given to an infant one year old. In severe cases this may be increased 
as the symptoms indicate. It should be given for the improvement in 
the pulse and in the strength of the patient. In cases of sudden col- 
lapse, it may be used hypodermically. Other heart stimulants are 
inferior to alcohol. In subacute cases, hygienic and dietetic measures 
must be depended upon; medicine does very little good. Opium is 
to be given only occasionally, as symptoms may require. 

Local Treatment. — This is of very great value in these forms of 
diarrhea. The lesions lie chiefly in the colon, and it is usually the 
lower half of the colon which is most seriously involved, according to the 
pathological anatomy, as will be seen by reference. Hence we can see 
that the proper mode of administration is by the rectum, and not by 
the mouth. 

Rectal injections are of two kinds : First, irrigation, which flushes 
out the entire colon as far as the ileo-ca?cal valve, large quantities of 
fluid being used and being allowed to flow in and out freely ; secondly, 
the use of enemata, in which a smaller amount of fluid is injected and 
retained for some time in the intestine, for its local effect. 

The method of irrigating the colon has already been described. 
(See Dyspeptic Diarrhea.") Its purpose is mainly to empty the intes- 



Cholera Infantum. 637 

tines completely of all masses they may contain. It need not be repeated 
more than twice daily, and nsnally once a day is enough. For an 
injecting fluid the normal saline solution — one dram of common salt 
to a pint of warm water — is less irritating than plain water. If there 
is much mucus, a borax solution of the same strength may be used. The 
water should flow in and out until it is quite clear, and from one to 
two gallons are used at one flushing. For general use a temperature 
of about 80° Fahrenheit is preferred. In cases of collapse, hot injec- 
tions (110° to 115° Fahrenheit) have been advised, and in cases of high 
temperature and active inflammatory symptoms, ice-water may be used 
with advantage. 

Enemata for local effect are generally used in quantities of from 
two to six ounces, according to the age of the patient. The intestines 
should first be emptied by an ordinary saline irrigation, except when 
nitrate of silver is to be used, when simple water should be employed. 
The injection, or clyster, is used about half an hour afterward, slowly 
introduced, the buttocks being firmly pressed together to prevent escape 
of the injection. A compress should be held against the anus by a 
nurse for from twenty to forty minutes, according to the nature of the 
enema and the effect aimed at. For use prepare as follows: First, 
bismuth subnitrate suspended in mucilage (mucil-acacia), a half dram 
of bismuth to one ounce of mucilage, from four to six ounces being 
injected, and retained as long as possible. 

Second, tannic acid dissolved in water, twenty grains to one ounce 
of mucilage ; use the same quantity and in the same way as the bismuth 
solution. 

Third, nitrate of silver, two grains to one ounce of mucilage ; 
inject only four ounces, and let it remain five minutes, then follow 
with a copious saline injection. To all of these — or whichever one is 
to be used — may be added tincture of opium, the amount being about 
twice the amount you would give by the mouth as a full dose, accord- 
ing to the age of the child. Of these prescriptions the first two are 
preferred. (W. Pepper, M. D., LL. D.) 

In general, intestinal irrigation is more useful than enemata. 
It is valuable in all varieties and in all stages. It may be combined 
with a small injection of four or six ounces to fill the rectum and sig- 
moid flexure, but not any more. The small clysters are most valuable 
when these parts are the chief seat of disease, as in the so-called dysen- 
teric stools. In these cases they are of great value, as are also small 
injections of ice-water. For tenesmus when not relieved by these 
measures, suppositories containing half a grain of cocaine may be used, 
and sometimes they act like magic. In subacute cases our choice is 
between simple irrigation and high injections of bismuth or tannic acid 
solutions. Their use may be continued for several weeks with 
advantage, the injections being alternated from time to time. 

During convalescence it is better to stop all treatment with refer- 
ence to the bowels, and direct our entire efforts in the line of general 



638 Cholera Infantum. 

tonic measures. The most useful are arsenic, of which one or two doses 
of Fowler's solution may be given three times daily for several weeks. 
Iron is one of the best preparations for infants ; use the albuminate 
prepared by Fraser & Company, New York City. The dose is from 
ten to thirty drops for an infant. Nux vomica may be combined with 
either of the above ; wine, either old port or sherry, may be combined 
with bitters if there is thought to be any danger of forming a habit. 
The mineral acids are useful, especially the nitre-hydrochloric acid ; 
two to five drops of the diluted acid may be given after meals, largely 
diluted in water. Later on cod-liver oil is beneficial. 

CHRONIC DIARRHEA OF YOUNG CHILDREN. 

The chronic intestinal catarrh of infancy is in a great majority 
of cases the result of improper feeding. When it occurs in breast-fed 
infants, the mother's milk may be the cause, especially if the mother 
is eating articles of food that affect her milkj as cabbages, turnips, 
sweet-potatoes, etc., or pregnancy will disturb the infant's bowels, and 
so the mother's milk must be looked upon with suspicion. Sometimes 
excessive frequency of feeding will derange the digestion in feeble 
children. No artificial foods are as yet made which will compare 
equally with human milk; therefore when chronic catarrh in a bottle- 
fed child does not yield to careful treatment, it may be essential to 
procure a wet-nurse. 

The proper hygienic condition of a wet-nurse should always be 
looked after; much harm is often done by pampering. 

The most generally applicable substitute for human milk is that 
of the cow, which is made better for infants by sterilizing. For the 
first three months of the babe's life, the milk should be diluted with two 
parts of boiled water ; for the second three months of life, equal parts 
of boiled water may be added ; after nine months the milk can be given 
undiluted. Excessive dilution of the milk often confuses a case tem- 
porarily, when the only symptoms are that the child is constantly cry- 
ing, constantly taking food, and constantly urinating. The child is 
crying from excessive hunger, and urinating constantly to get rid of 
the water. When any intestinal catarrh refuses to yield to treatment 
while the child is being carefully fed with cow's milk, artificial foods 
may be tried. Of these the most popular are largely composed of grape 
sugar. The various artificial foods have been sufficiently discussed in 
the article on acute dyspeptic diarrhea to enable one to select those that 
will be of value in chronic cases. 

The hygienic management of the infant suffering from chronic 
intestinal catarrh is very important. In the summer it should be 
bathed in cool water and be protected from the heat, and in the winter 
from the cold, and it should at all times wear a woolen abdominal 
bandage. 

The medical treatment in chronic intestinal catarrh in childhood 
can be outlined in a few words. The most important principle is 



Cholera Infantum. 639 

to avoid all astringent remedies as far as possible, and attempt to cure 
the catarrh, and not the diarrhea, which is its symptom. Mercurials 
are of value ; minute doses of calomel or gray powder may occasionally 
be given for several days at a time with advantage. Bismuth sub- 
nitrate is very much used; it may be given in from five to ten-grain 
doses three times a day. Intestinal antiseptics are important. Salol, 
creosote, naphthol, salicylate of sodium, or strontium salicylate may be 
used from time to time, alone or in combination with bismuth, often 
very advantageously. The one drug that is most generally used with 
best results is said to be sodium phosphate ; it is rather laxative than 
astringent, but evidently favorably modifies the intestinal secretions. 
From five to ten grains of it should be given with each bottle of milk 
or immediately after the taking of the food. 



CHAPTER L. 
CHRONIC MEMBRANOUS ENTERITIS. 

This variety of chronic enteritis has been designated pseudo- 
membranous colitis and mucous colic. 

t It usually occurs in women and sometimes in children. It occurs 
most often in neurasthenic persons. There may exist two distinct con- 
ditions, the one innammatory, the other a neurosis. The essential 
characteristic is the discharge from the intestines of a gray mucus, 
opaque, in the form of membrane or of cords, sometimes a foot or more 
in length, and of tubular casts of portions of the intestines, often dis- 
colored by intestinal contents and even blood. 

Symptoms. — Pseudo-membranous enteritis is characterized by 
attacks of colic, followed by evacuations of the typical discharges. The 
attacks of colic may last for several days, when relief is experienced, 
and an interval of months may elapse before a recurrence of the 
symptoms. With repeated attacks come depression of spirits and 
hysterical manifestations, and neurasthenic symptoms are frequent. 
The general nutrition and appearance of the patient may be but little 
affected. Pseudo-membranous colitis is usually an affection of long 
duration, and treatment is generally of but little avail. 

We have three varieties: First, those cases in which there is 
habitual constipation; second, those in which there is a tendency 10 
relaxation of the bowels; third, those in which constipation and diar- 
rhea alternate. The management of these varieties of the disease dif- 
fers, but at the same time has much in common. 

Treatment. — In every case the hygienic management must be in 
accord with the general condition. Neurasthenia may be more pro- 
nounced in bad cases ; in these the rest-cure should be enforced with a 
rigor proportionate to the needs of the individual. Then, again, even 
from the onset a little exercise, gradually increased, is required. Under 
all circumstances the abdominal bandage should be used day and night, 
and it must be made to fit, and be kept continually in place. Cool or 
tepid-water bathing may be indulged in as indicated. The diet should be 
carefully watched, and should be about the same as in chronic enteritis. 
Not much sugar should be used. Oatmeal must be prohibited ; wheat 
foods may be used in some cases. Potatoes, beets, and all vegetables 
which grow under the ground should be strictly forbidden, while 
spinach, young peas, and lima beans may be eaten sparingly. Maca- 
roni without cheese, rice, and milk foods are usually suitable, and 
plain pudding and custard may sometimes be allowed. Hot bread and 

(640) 



Chronic Membranous Enteritis. 641 

griddle-ca^es are to be interdicted, and even stale bread must be spar- 
ingly used. Tea may be allowed, but coffee and chocolate are on the 
doubtful list. Alcohol in any form should be used with caution; malt 
liquors are especially injurious. 

During the fever stage the patient should be kept quiet, confined 
in bed. A free use should be made of counter-irritation along the 
whole length of the colon by means of iodine, or even flying blisters, 
and full doses of castor-oil should be taken until its effects have become 
manifest, at the same time using large injections, as described. Two 
quarts of water at 105 degrees Fahrenheit may be used three or four 
times a week, with a level teaspoonful of salt or borax added to each 
quart. A mild nitrate of silver injection, five grains to one quart of 
water, is recommended to be used once a week. Relief can not be 
expected until the membranous masses are thrown off. Between 
exacerbations the treatment varies with the case. The following, con- 
taining tar, is recommended: — 

9: Picis liquidse f,liii 

Triturentur cum liquore calcis oviii 

Ad saturationem et percolentur per 
prunum virginianam 3viii 

Sig. : Take a wineglassful one or two hours after each meal. This 
may be given continuously for weeks in every form of the disease. 

When there is distinct diarrhea, carbolic acid and bismuth are 
very useful, prepared as follows: — 

li: Bismuth subcarbonates 3iii 

Acidi carbolici gr. xv 

Misce et dispensa in capsulis xxiv. 

Sig. : One or two every two or three hours till relieved of the 
diarrhea. 

Xo astringent should be employed more severe than sulphuric- 
acid mixture, with guarana occasionally after meals. When there is 
constipation it is essential that the bowels be kept freely open day after 
day, and no hesitation should be felt in the use of laxatives. The 
daily use of glycerine and castor-oil will help some cases effectually. 
These laxatives should be varied. Use sodium phosphate, cascara 
sagrada (aloes, belladonna, and strychnine), or pills (Park, Davies). 
The following is recommended: — 

1$: Sodii phosphatis 3111 

Sodii sulphatis . Jj 

Potassi aodidi 3j 

Misce et fiat pulvis. Subtilissimus. (Mix fine.) 

M. sig. : A teaspoonful to a tablespoonful as required, to be taken 

in water. 

Many individuals are greatly benefited by taking, after each meal, 

one to two tablespoonfuls of sweet-oil with lemon or a little whisky. 

Any derangement of the digestion from the use of the oil should cause 

it to be immediately discontinued. 

41 



642 Chronic Membranous Enteritis. 

It is thought that the most important part of the treatment in 
these cases is habitual use of large enemata of warm flaxseed tea, which 
may be employed three or four times a week, finally reduced to one a 
week. Two quarts of thin flaxseed tea may be used at a temperature 
of 105° Fahrenheit; a little borax may be added or ten to twenty 
grains of boracic acid ; or a normal salt solution may be used. 

ULCERATIVE ENTERITIS. 

Ulcers of the intestines arise from a variety of causes ; they usually 
develop in the mucous membrane^ and sometimes in the serous coat. 
The most conspicuous characteristics of the disease occur in acute and 
chronic infectious diseases, such as typhoid fever, dysentery, tubercu- 
losis, and syphilis; in constitutional affections, such as scurvy, gout, 
diabetes, malignant disease, and especially cancer; in those due to 
sharply-defined causes, as strangulation of the bowels in acute intes- 
tinal obstructions or localized disturbances of circulation, and in ulcers 
of the duodenum, and those from thrombosis and embolism. 

Catarrhal ulcers are especially found in the large intestine. They 
may be few or many, and are often found in the rectum. 

The follicular ulcers are usually developed in the large intestine, 
and sometimes are seen in the ileum and represent one of the results 
of follicular enteritis in which the inflamed lymph follicles become 
abscesses and are discharged into the intestines. The ulcer is deep- 
seated from the commencement. 

Retention of inspissated faeces in the large intestines will cause 
ulcers, called "stercoral ulcers." This variety is said to be of special 
importance in appendicitis. 

Symptoms. — Ulcers of the intestines, whatever may be the cause, 
are said to have but few characteristic symptoms ; extensive ulceration 
of the intestines may exist, and there be no symptoms specially indica- 
tive of this lesion. They are, as a rule, more numerous ; and the 
larger the ulcer, the more likely is diarrhea to be present, and the course 
of the affection is that of a mild or severe form of acute or chronic 
catarrhal enteritis. Ulcers may occur in the large intestines with 
either no diarrhea, or with alternating constipation and diarrhea. 
When there is any pain, it is of a colicky character and causes persist- 
ent discomfort. If there is any tenderness in the region where the 
pain exists, there may be extension of the ulceration to the vicinity of 
the peritoneum. Blood, pus, or shreds of tissue in the stools are indica- 
tive of ulcer. The pus may be so small in quantity as to be over- 
looked; it is well to remember this. Shreds of tissue are said to be 
absolutely characteristic of ulcer. Large quantities of pus in the intes- 
tinal evacuations are not so suggestive of ulceration as of the perfora- 
tion of a neighboring abscess into the intestines. 

Treatment. — This should be practically the same as for chronic 
catarrhal enteritis. Its hygienic management is extremely important. 



Chronic Membranous Enteritis. 643 

At no time should any chilling of the surface be allowed; a heavy, 
well-fitting woolen or silk bandage over the abdomen is vital, and 
should be worn continuously, being changed day and night. A long- 
sleeved woolen or silk vest or undershirt must be worn day and night ; 
the ankles should always be well covered and protected from draughts ; 
the patient should on no account be allowed to put the naked foot upon 
even a carpeted floor, and in cool weather shoes should be worn instead 
of slippers even in the house. The drinking must be carefully attended 
to. Ice-cold liquids are to be forbidden, and no sweet drink allowed, 
nor much wine. In some cases, strong wines, such as port and Madeira, 
may be given very sparingly; but alcohol, ordinarily, if taken should 
be well diluted; pure brandy is to be preferred to whisky. Coffee 
should not be allowed at all; tea may be used in moderation; skim- 
milk is sometimes advantageous. In some cases scraped steak, Ham- 
burg steak, or broiled or baked tender meats may be given, while veal, 
turkey, pork, and tame duck are absolutely forbidden. Starchy foods 
are rarely allowable ; toasted breads may be allowed, but the various 
farinaceous dishes are contra-indicated. Macaroni stewed in milk 
without cheese agrees with most cases, and rice may be used if necessary 
to satisfy the craving for vegetables. In general, no vegetables should 
be taken. Custards and other simple, plain puddings without much 
sugar, are to be put on all except the strict-diet lists; eggs not cooked 
may be taken in moderation. 

The amount of exercise allowed must be carefully suited to the 
individual case. !N"ot rarely there is a pronounced exhaustion, and 
rest in bed with massage is essential ; on the other hand, an old enteritis 
is sometimes benefited by carefully-graded exercise. The main reliance 
must be upon local treatment. Intestinal antiseptics are chiefly of 
value, as they benefit complicating conditions of the upper bowel. 
Bismuth and tar preparations when given by the mouth, may to some 
extent reach the large intestines. It is said that the most remarkable 
effects are at times obtained from a large injection of two quarts of 
water containing one-half to one dram of nitrate of silver. Such 
injections may be repeated in three or four days and perhaps then once 
a week. Between these injections the bowels may be washed out with 
a saturated solution of borax once in three or four days. Fluid ..extract 
of hydrastis is recommended to be put into the injections for healing 
the ulcers. 

DIPHTHERITIC ENTERITIS. 

The treatment of diphtheritic enteritis is largely that of its cause, 
with the addition of such general and local measures as have been pre- 
scribed under the head of acute and chronic enteritis and of dysentery. 

PHLEGMONOUS AND GANGRENOUS ENTERITIS. 

When the mucous membrane is infiltrated with pus, the condition 
is known as phlegmonous enteritis. It is of rare occurrence, and may 



644 Chronic Membranous Enteritis. 

be the result of a primary infection of the wall, as in malignant pus- 
tules. More often it occurs in consequence of ulcers, intestinal obstruc- 
tions, strangulated hernia, or faecal impaction. The symptoms are those 
either of severe enteritis or of a peritonitis. 

Gangrenous enteritis occurs when putrefaction of the necrotic 
mucous membrane occurs. It therefore represents a stage in the 
progress of ulcerative, diphtheritic, or phlegmonous inflammation of 
the intestines. It is oftenest present in dysentery, and is indicated by 
the discharge of discolored sloughs of an extremely offensive odor, with 
considerable blood. Further explanation will be found in the article 
dn dysentery. 

Phlegmonous and gangrenous enteritis must be looked upon as 
secondary or complicating disorders, for which there is no other treat- 
ment than that of the original cause, with the use of opiates or laxa- 
tives or astringents, and of the various local remedies to meet symp- 
toms as they arise, the same as have been advised in the foregoing 
enteric diseases. 



CHAPTEE LI. 
JAUNDICE (ICTEKUS). 

Definition. — Jaundice is a pathological yellow discoloration of 
skin and many of the tissues and fluids of the body, usually, if not 
invariably, due to bile-pigment, and occurring in many diseases and 
under a variety of conditions. 

Etiology. — It is now generally admitted, since the researches of 
Stademann, that all cases of jaundice are due to obstructions of the 
outflow of bile from the liver, and the absorption of its pigment through 
the lymphatics of the liver ; for there is no absorption of bile when the 
common bile-duct and the thoracic duct are tied. 

Any obstruction to the outflow of bile being the immediate cause 
of jaundice, it is convenient to consider that such obstructions may 
affect the common and hepatic bile-ducts or the intra-hepatic bile-ducts. 
Obstruction of the former may be produced by external causes, as con- 
striction from scars or compressions from tumors, whether neoplastic, 
aneurismal, parasitic (echinococcus), or fecal. The internal causes 
producing obstruction are inflammation, stricture, tumors, or fallen 
bodies. The external causes of obstruction of the intrahepatic ducts 
are the various inflammations of the liver and the tumors and para- 
sites of this organ. Passive congestion and fatty infiltration are also 
causes. The internal causes are catarrhal and suppurative inflamma- 
tion, calculi, concretions, and inspissated bile. 

New-born babies so frequently become jaundiced that this con- 
dition deserves a separate consideration from the same affection occur- 
ring in older children and in adults. 

The experiments of Stern in ' removing the liver from pigeons 
resulted in producing hemoglobinemia, but failed in inducing icterus. 
Erom these experiments the presence of the liver would seem to be 
necessary to produce the jaundice, in addition to a large amount of 
coloring matter circulating in the blood. 

It is generally considered that the coloring matter of the bile is 
derived from the coloring matter of the blood ; but the transformation 
takes place by means of the liver. In vigorous, healthy infants, the 
liver will change the liberated hemoglobin into biliary coloring matter 
in a few days, and this will be eliminated by the excreta. If the infant 
is feeble or diseased, this transformation and elimination will not so 
readily take place, and jaundice will be one of the results. Thus the 
theory of Quincke explains certain cases of icterus on the ground that 
the ductus-venosus may remain open for some time after birth, thereby 

(645) 



646 Jaundice. 

allowing a part of the portal blood containing bile to pass directly into 
the general circulation. Ashby reports a case in which an autopsy 
showed the ductus- venosus to be widely open in a jaundiced infant who 
died on the eleventh day. He believes that this duct is liable to remain 
open longer in feeble and immature infants than in more vigorous ones. 
Jaundice is certainly much more likely to develop in the former than in 
the latter class of infants. 

Symptoms. — The intense condition of the skin noticed during the 
first few hours or days of life, often produces a yellowish coloration 
that can not be considered a jaundiced state, since it is dependent upon 
q, secretion of bile. The yellow tint is at first seen only on deep pres- 
sure, but as the redness fades away, the yellowness increases. The 
conjunctivae are colored, and the urine appears normal. The yellow- 
ness is noticed on the second day, and may continue a few days or a 
week. This discoloration of the skin is more often seen in cases of 
prolonged labor and in difficult labor, in infants born asphyxiated or 
before term, and, in general, in feeble infants. 

Grave icterus neonatorium is, fortunately, very rare, and may be 
produced by several different conditions. Defects in the bile-ducts will 
first be considered, as among the most common causes. In some cases 
all the largest bile-ducts have been absent ; in others, as reported, the 
ductus communis choledochus has been narrowed or obliterated, or is 
entirely absent. Sometimes a fibrous cord has been found in place of 
the gall-duct. The cystic duct has been absent, and the gall-bladder is 
in a rudimentary condition. Accompanying an obliteration of the gall- 
ducts, a condition of cirrhosis is usually found in the liver, which will 
be more or less marked according to the length of time that the infant 
survives. The liver is usually found enlarged. 

Another grave form of icterus in the newly-born is seen in con- 
nection with septic poisonings. That is generally accompanied by 
umbilical phlebitis. Shortly after birth, the umbilicus is a very dan- 
gerous spot for the entrance of septic poisons. Infected air or pus 
can readily enter the umbilical vein from the umbilicus, and thus start 
up umbilical phlebitis and general septicemia. This grave accident is 
liable to occur when the mother is in a septic condition. The poison 
may be introduced by bacteria, which are probably the same agents that 
produce the puerperal fever. In these cases of sepsis there is a puri- 
form or yellow softening of the thrombi that fill up the umbilical vein. 
This sets up an inflammation not only in the vessel itself, but in the 
surrounding tissues. Infecting emboli may be carried to various parts 
of the body. 

The septic form of jaundice comes on shortly after birth, usually 
within a few days, and is soon well marked. 

A third cause of grave icterus neonatorum is found in certain 
inflammatory changes in the liver, usually taking the form of an inter- 
stitial hepatitis, and may be conjoined inflammation of the biliary 
canals. 



Jaundice. 647 

Diagnosis. — The first point is to make the differential diagnosis 
from false jaundice. In the false case, the discoloration being due to 
the remains of a severe cutaneous congestion, there is a yellowish-brown 
tint usually present, while in true jaundice the color of the skin is more 
markedly yellow. In true jaundice the conjunctiva? and urine usually 
present an icteric tint which is absent in false jaundice. 

Septic jaundice must be treated by free stimulation and all other 
measures that can be employed in sepsis. In cases of umbilical hemor- 
rhage, applications of strong astringents, such as the perchloride or 
subsulphate of iron, may be made. It may be necessary to apply a 
ligature around two harelip pins inserted through the skin at the navel. 

JAUNDICE IN OLDER CHILDREN. 

The jaundice that attacks older infants or children is due to 
causes that are similar to those found in adults, which have been 
described in foregoing articles. 

Symptoms. — The yellow discoloration of the conjunctivae and skin 
is the same as in icterus neonatorum. A symptom often noted is a 
slow pulse, perhaps forty or fifty beats to the minute, as bile, when 
present in the blood, has a sedative effect upon the circulation. The 
biliary salts in the bile are the ingredients that produce this effect. 
If there is much slowing of the circulation, the respiration will like- 
wise diminish somewhat in frequency. The most marked symptom 
is duodenitis or a gastro-duodenitis. In the latter case there is more 
or less nausea and vomiting, with pain in the epigastrium, especially 
upon the ingestion of food. There may be a subacute duodenitis with- 
out gastritis being present. If so, there is pain and distress when the 
food passes from the stomach into the duodenum, which usually occurs 
some hours after the taking of nourishment. Conjoined with this there 
is tenderness on pressure below the epigastrium at the situation of the 
duodenum. In these cases a plug of mucus is said often to be found 
in the common duct where it opens' into the duodenum ; also the dis- 
turbances from obstruction to the passage of bile into the duodenum, 
depend upon the absorption of bile-pigment and bile-acids and the 
absence of bile from the intestinal contents. 

Within three or four days after the obstruction has taken place 
— and the earlier, the more sudden and complete the obstruction — the 
skin and visible mucous membrane become yellow. This color is first 
seen in the conjunctivae. Discoloration of the urine may be noticed 
even earlier than that of the skin; and as it increases in intensity, it 
assumes a dark-brown color, resembling porter. The urine readily 
foams when shaken, and the froth has a yellowish color. The quantity, 
reaction, and specific gravity are normal, and there is neither albumen 
nor sugar. The stools are clay-colored, from an excess of undigested 
fat, while no bile reaches the intestines. The complete absence of bile 
is shown by a quick decomposition of the intestinal contents, as exhib- 



648 Jaundice. 

ited in the free formation of gases and the foul odor of the faeces when 
voided. The bowels are usually constipated. Itching of the skin may 
cause great annoyance, especially at night when the skin is warm. 
Uticaria, which is an exceedingly common affection in children, may 
occur as an obstinate complication, when the papules and wheals will 
present a deep yellow tint. Jaundice may persist for a long time with- 
out giving rise to much apparent disturbance, as the system assumes 
a tolerance of an excess of bile. 

Diagnosis. — Evidence of the existence of gastro-duodenitis must 
first be sought for. When there is no nausea or vomiting, with pain 
about the region of the epigastrium that has preceded and accompanied 
the jaundice, these conditions may be recognized as causative. If the 
ducts are inflamed from other causes than a duodenitis, such as a 
roundworm in the common duct, the diagnosis, it is said, can not be 
made during life. If careful palpation reveals a distended gall- 
bladder, there is positive evidence of obstruction in the common duct. 

In cases in which jaundice is merely a symptom of some struc- 
tural affection of the liver, not only diagnosis, but also treatment, must 
be adjusted with reference to the latter lesion. The jaundice is sim- 
ply one among many other symptoms. 

It is necessary to bear in mind the fact that jaundice may be dis- 
tinguished from other abnormal tints of the skin simulating it by the 
yellowish conjunctivae and by the presence of biliary pigment in the 
urine. The latter condition is absent in the yellowish-green tint some- 
times seen in chlorotic girls, and in any other abnormal discoloration 
of the skin. 

Prognosis. — The prognosis, of course, will depend upon the ascer- 
tained cause of the jaundice. A jaundice that persists indefinitely, 
even where no organic disease can be found, must not be regarded with- 
out apprehension. If the general health and strength are good, a jaun- 
dice may last for several months without causing any special alarm; 
but cases that persist for one or two years are apt to produce grave 
changes in the nutrition of the patient. Sometimes even mild cases 
of jaundice may suddenly present evidence of blood-poisoning, which 
may be followed by death. Fortunately, the majority of cases of jaun- 
dice seen in young children disappear in a few weeks without leaving 
any serious consequences. 

Acute jaundice lasts several weeks ; chronic jaundice extends over 
several months or years. Acute jaundice — catarrhal — usually termi- 
nates favorably within six weeks ; yet fatal yellow atrophy of the liver 
may be preceded by a fortnight of apparently simple catarrhal jaun- 
dice. Acute jaundice from gall-stones, as a rule, rapidly subsides with 
the cessation of the biliary colic. The prognosis of acute febrile jaun- 
dice is uncertain during the persistence of the fever, in consequence 
of the gravity of the complications which may arise. Chronic jaundice, 
especially when increasing in intensity, is of serious if not grave impor- 



Jaundice. 649 

tance, particularly if without fever and pain; then persistence, with 
cachexia, is suggestive of malignant disease of the liver. 

Treatment. — The treatment of jaundice is often necessarily empir- 
ical. Whatever the cause, certain symptoms are usually present that 
must be alleviated by treatment. Persistent constipation is one of 
the commonest of these symptoms. Small doses of aloes, rhubarb, or 
castor-oil will fulfil this indication. 

Drugs which act by irritating the trouble must be avoided in the 
common cases of duodenal catarrh. The saline laxatives or mineral 
waters are best used to cause a suitable action of the bowels when there 
is catarrh of the duodenum. Carlsbad, Vichy, and Congress waters 
usually act well. Great care must be paid to diet, only bland and 
easily-digested foods being allowed. All fatty articles must be 
restricted, and the patient kept upon lean meat and plain vegetable 
food. In some cases counter-irritation in the shape of a small blister 
at the epigastrium appears to do good. Active peristaltic action in 
the duodenum may be transmitted to the bile-ducts, and thus in the 
beginning an obstruction may be overcome. Calomel, rhubarb, aloes, 
and colocynth may be used in these cases. The action of an emetic, by 
forcibly compressing the liver and bile-ducts, may free the passages 
from obstruction. Alkalies, the bicarbonate of sodium and potassium 
bicarbonate, are supposed to have a liquefying effect upon the bile, and 
thus to free the ducts when they are occluded by a thickening of this 
secretion. 

Tincture of mix vomica may be combined with advantage when 
one of the sodium salts is prescribed. Nitre-hydrochloric acid is highly 
recommended by some authorities. Henoch claims good results for it 
in obstinate catarrhal jaundice. 

When jaundice persists, and resists ordinary treatment, efforts 
must be directed to eliminating some of the bile from the system by 
means of the emunctories. This is said to be done by the kidneys and 
cutaneous glands. The mild vegetable diuretics, the acetate of potas- 
sium, and various mineral waters, such as seltzer, have been recom- 
mended. It is advised to give lemon juice also, from one to three 
ounces daily to an adult. It agrees with digestion and excites an 
abundant diuresis. The skin may be kept acting freely by means of 
warm baths, and by having pure flannels worn to guard against changes 
of temperature. Everything must be done to support and invigorate 
the system, so as to obviate as far as possible the depressing effects 
of the cholemia. 

The first sign of improvement, in case of a favorable issue, will 
be the disappearance of the biliary coloring matter from the urine. 
The real affection has then ceased, although the skin may retain its 
jaundiced hue for some time longer. 



CHAPTER ML 

DISEASES OF THE BILIARY DUCTS. 

Affection of the biliary ducts in children practically resolve? 
itself into an inflammation secondary to a like pathological condition 
of the gastro-intestinal mucous membrane, as the lining membrane of 
^the duodenum is directly continuous with that of the bile-ducts; also 
to the occasional wandering of entozoa from the intestine into these 
ducts. 

CATARRH OF THE BILIARY DUCTS. 

A catarrhal inflammation of the ducts of the liver will produce 
changes similar to those seen in other mucous membranes. The mucous 
membrane of the gall-bladder may be the seat of catarrhal inflamma- 
tion and the ducts not be involved. This is said to take place from 
thickening and alteration of bile that has remained for a long time 
stagnant in the gall-bladder. 

Etiology. — Acute indigestion produced by overloading the stomach 
with all kinds of improper food and drink stands as the common cause. 
Certain infectious diseases, and acute or chronic malarial attacks may 
cause enough gastro-duodenal irritation to provoke an actual catarrhal 
inflammation. 

Symptoms. — In the beginning there are apt to be various diges- 
tive disturbances, shown by coated tongue, nausea or vomiting, and 
disinclination to take food. There may be slight fever and other symp- 
toms pointing to a mild catarrh of the stomach. In a few days the 
conjunctiva? begin to be tinged with yellow, and the urine is colored 
by biliary pigment; soon a marked jaundice develops, and the fseces 
lose color and become clay-like in appearance. There is often a 
slight enlargement of the liver, which projects a little below the ribs, 
and the gall-bladder may likewise be felt projecting below the 
margin of the liver, assuming a sort of pear shape. The jaundice 
accompanying this affection generally lasts two or three weeks, although 
it may not disappear for two or three months when the inflammation 
of the duodenum and bile-ducts is severe and chronic. At first there is 
tenderness on pressure over the epigastrium and right hypochondrium. 
Its duration will, of course, depend upon the nature of the original 
hepatic disturbance. If the gall-bladder alone is the seat of catarrhal 
inflammation, there will be no jaundice, and the symptoms in general 
will be very indistinct. 

Diagnosis. — This consists in recognizing the existence of a gastro- 

(650) 



Diseases of the Biliary Ducts. 651 

duodenal catarrh, or seeking carefully for some affection of the paren- 
chyma of the liver that may induce a catarrhal inflammation of the 
biliary ducts. 

Treatment. — The treatment is essentially the same as that recom- 
mended for ordinary jaundice in children. 

EOUNDWOEMS IK BILE-DUCTS. 

It rarely happens that roundworms find their way into the biliary 
ducts and produce grave or fatal symptoms. The worm enters by the 
common duct into the gall-bladder from the stomach. Cases are 
recorded where a worm has been found partly within the common duct 
and partly in the duodenum. The symptoms are said to be too obscure 
to warrant a diagnosis. There may be acute pain in the epigastrium, 
with vomiting, and finally convulsions. Treatment must be directed 
to symptoms. 

LITHEMIA. 

Children often suffer from a functional disturbance of the liver 
that gives rise to various digestive and nervous symptoms. The prin- 
cipal evidence of faulty nutrition will be found in the urine. The 
tongue is coated, and the breath offensive. Constipation is usually 
present, and the stools are pasty, like bile. There is an unhealthy 
appetite, sometimes abnormally large, and the children have a pale, 
sallow appearance. Complaint is commonly made of headache. Young 
children become extremely fretful when suffering from this affection. 
They wish to v urinate frequently, and a reddish-pink sediment of urates 
is deposited in the chamber. Anemic girls are very apt to become 
lithemic before or at the time they begin to menstruate. 

Treatment. — The first object of treatment is to get the bowels 
acting regularly; a few small doses of calomel may first be given, fol- 
lowed by fluid extract of cascara sagrada or aloes. !N"ux vomica com- 
bined with an alkali such as bicarbonate of potassium, or an acid such 
as dilute hydrochloric acid, may then be administered. Good effects 
will often be obtained by changing from an acid to an alkali, or vice 
versa. The diet of the child should be carefully regulated. Too much 
meat, as well as an excess of starchy foods, must be avoided. Pastry 
and sweets must be withheld entirely. Plenty of outdoor exercise, 
well-ventilated rooms, salt baths with friction of the skin, and all kinds 
of beneficial hygienic measures, may be employed with great advantage. 



CHAPTEK LIII. 
ACUTE AND CHRONIC CONSTIPATION IN CHILDKEN. 

Definition. — This condition involves a delayed expulsion of the 
faecal matter, a retention of intestinal excrementitious substances beyond 
the normal period, infrequent or incomplete alvine discharges, or a 
scarcity or complete absence of faecal evacuations. 

Constipation is not so much a disease in itself as it is a symptom 
of various morbid conditions. There are certain anatomical, physio- 
logical, and dietetic reasons for constipation in children that do not exist 
in the adult. The small intestines are relatively longer and the cali- 
ber smaller in children than in adults. The walls are also thinner and 
weaker. The ascending and the transverse colon are shorter compared 
with the adult, and the descending portion is longer. According to 
Jacobi, the length of the intestinal tract in children, with its tendency 
to overlap and elongate, is a cause not only of constipation but also 
of the more serious surgical difficulties, such as intussusception, etc. 
Treves has pointed out the anatomical changes in the colon that almost 
always attend chronic constipation. 

Physiology. — In a healthy child the mother's milk is almost 
entirely absorbed and assimilated, leaving but a small residue, and the 
amount of material evacuated has some relation to the amount taken 
into the system. The albumen of the milk is nearly all digested in 
the stomach and bowels of the child, and from this very process we have 
a physiological cause of constipation in children, faecal matter existing 
in such small quantities that intestinal peristalsis is not excited; in 
older children and adults, if constipation has not become habitual, the 
rectum is usually empty. When defecation is regular, the faecal mass 
descends into the rectum and produces the uneasy sensation which pre- 
cedes a healthy evacuation. If this call is not heeded, a reverse peri- 
stalsis is excited in the walls of the rectum, and the faecal matter is 
returned to the sigmoid flexure. If this neglect becomes habitual, the 
return to the upper bowel does not take place, and an accumulation 
follows, with all its attendant evils to pelvic circulation. 

In a small number of cases, one evacuation each day may be suffi- 
cient; but frequently where this is the case some of the deleterious 
results of constipation will be noticed. On the other hand, we have 
frequently noted from three to four movements each day, and have 
found by actual weight of the child, a normal increase from week to 
week, with every other indication of good development. From one to 
four passages each day, then, would be regarded as normal. Devia- 
(652) 



Acute and Chronic Constipation in Children. 653 

tions from the normal have been noted, such as an evacuation every 
time a napkin is changed during the first year of infant life, to a pas- 
sage once in seven or eight days, and in the older literature instances 
are recorded of a single passage in several months. A gradual increase 
in weight and a generally good condition of nutrition must be our guide 
in deciding this question. 

Constipation is undoubtedly more frequent in adults than in chil- 
dren; in adults it is perfectly natural for at least three or four evacu- 
ations of the bowels to take place daily. Between the first and second 
year it is normal for two daily movements to take place. In all proba- 
bility what we call family peculiarities are largely due to neglect of 
proper attention to the wants or habits of children, or to the perpetua- 
tion of a family habit of continually giving and taking purgatives. 
In every case it is necessary not only to inquire as regards this family 
peculiarity, but also to consider the character as well as the frequency 
of the intestinal discharges. Interference with normal peristalsis, 
which may come from many causes, will produce most remarkable vari- 
ations in the normal evacuation as well as in the nutrition of the child. 

Etiology. — We will consider the infant at breast first, more espe- 
cially the causes of constipation, and then the older children. A consti- 
pated habit on the part of the mother has frequently something to do 
with the constipation of the child. The mother's milk sometimes con- 
tains too much caseine or too little sugar, and in other cases is so thor- 
oughly digested that but little residue remains, and constipation ensues. 
(Bouchard.) 

A sluggish condition of the muscular coat of the intestine, a 
diminution in the secretions either from the mucous membrane or 
from the glandular apparatus, and improper food, are other causes, to 
which may be added imperfect muscular development in feeble and 
delicate children. 

Artificial foods, including condensed milk, in many instances pro- 
duce diarrhea, but in other cases give 'rise to constipation ; and any food 
which absorbs quickly, leaving little or no residue, will produce this 
condition. To obviate this, if water has not been used as a diluent, 
oatmeal water should be substituted. In older children solid food, or 
vegetables with a large residue, or fruits, such as bananas, with an 
insufficient amount of liquids, in connection with a condition of the 
bowels favoring retention, are frequently causes of constipation. 
Overstimulation and consequent atony of the bowel, whether from 
coarse food, frequent purgations, or large enemata, are also causes. 

Among other articles of food which may produce constipation are 
rice, arrowroot, boiled milk, and tea. Impaction of the bowel, espe- 
cially in the lower part, may take place from a variety of causes, such 
as large masses of hardened faecal matter, fig pits, raspberry seeds, and 
stones from fruits. It is believed that intestinal worms will give rise 
to the conditions described. Deficient intestinal secretion, by produc- 



654 Acute and Chronic Constipation in Children. 

ing a hard and pebbly condition of the f aecal mass by the time it reaches 
the colon and rectum, causes constipation. Where there is a deficiency, 
particularly in the bile or other secretions, and articles of food which 
cause fermentation are taken, an enormous accumulation of gas may 
take place, producing not only constipation, but sometimes convulsions. 

All kinds of medicines administered to quiet pain or restlessness, 
whether prescribed by the physician or nurse, are constipating. The 
same may be said of many tonics which contain astringents, particu- 
larly tannin; also the too free use of aperient medicines, producing 
overstimulation and subsequent enfeeblement of muscular activity. 
g All local diseases of the rectum, as fissures and haemorrhoids, pro- 
ducing painful passages, predispose to constipation in children the 
same as in adults. The child delays its normal movement from dread 
of stool on account of pain, and soon there results distention of the 
lower bowel from accumulation, which, although secondary, produces 
the malady under consideration. A neglect of inculcating habits of 
regularity in going to the closet, the false modesty felt by young girls, 
especially when traveling, the inactivity of indoor life and a want of 
exercise, induce constipation. In most young girls subject to consti- 
pation, we invariably find anaemia and neuralgia. 

Constipation is also due to hernia, intussusception, intestinal 
obstruction from carcinoma, and congenital malformations of the rec- 
tum. It may be caused by chronic peritonitis, by tumors, and, in the 
female child, by a retroflexed uterus. (C. W. Earle, M. D.) Many 
other causes produce constipation, as cases of meningitis, myelitis, 
hydrocephalus, and microcephalus in children. 

The bowels are sluggish in the diseases of the cerebro-spinal sys- 
tem; this is said to be due, in part, to interruptions in the motor nerve- 
currents, or to a state of tonic contraction in the abdominal and intes- 
tinal structures. Finally, in many of the chronic and wasting diseases, 
especially those enfeebling the muscular movements having to do with 
defecation, and, in general, producing a low condition of the system, 
constipation is present. 

CONSTIPATION FROM PARALYSIS OF THE INTESTINES. 

Constipation may result from either primary or secondary inflam- 
mation of the muscular coat (by extension from the mucous membrane). 
It is not uncommon to find in children ulcerations of the mucous mem- 
brane which had previously caused diarrhea, suddenly give rise to 
considerable abdominal distention and a most obstinate constipation. 

AFFECTIONS OF THE NERVE-CENTERS. 

In disease of the brain and its membranes, as in tubercular- 
meningitis, constipation is almost always the rule, and sometimes in 
acute meningitis; also in serous or hemorrhagic meningeal effusion, 
in softening of the brain, in cerebral congestion, and in tumors of the 
brain. 



Acute and Chronic Constipation in Children. 655 

Affections of the spinal cord or its membranes — as spinal menin- 
gitis, congestion, or hemorrhage, acute or chronic myelitis and tumors — 
are more frequent causes of constipation than are cerebral affections. 
A most obstinate constipation due to paralysis of the sphincters of the 
anus, sometimes marks the onset of locomotor ataxia. Paralysis of the 
diaphragm or of the abdominal muscles, or neuralgia of these muscles, 
leads to constipation, by preventing their action, the least motion 
occasioning pain. 

CONSTIPATION FEOM REFLEX INTESTINAL PARALYSIS. 

This is said to be the result of affections of organs more or less in 
the vicinity of the intestines, as a testicle retained in the inguinal canal 
becoming inflamed; or affections of organs connected with the intes- 
tines, as hernia of the vermiform appendix, umbilical hernia, and 
abscess in the iliac fossa. A proof that constipation resulting from the 
above causes is reflex, is afforded by the fact that the phenomenon of 
paralysis is preceded, as in all reflex paralysis, by signs of irritation, as 
pain, vomiting, and abdominal distention. To the above causes may 
be added lack of sensibility of the mucous membrane of the intestines. 
The result of this is seen in persons who do much brain work, or lead 
a sedentary life, and who make an abuse of rectal enemata, or of cer- 
tain medicines, as opium, purgatives, etc., which act by diminishing 
sensibility of the mucous membrane. Opium, however, would cause 
paralysis of the muscular coat. 

CONSTIPATION FROM AN ALTERED STATE OF THE BLOOD. 

This cause, as stated by Maingualt and others, produces constipa- 
tion either by its effects on the intestinal secretions, or by its direct 
influence on the nervous system. Thus, in convalescence from acute 
diseases, we may have paralysis of the muscles of the intestines, as we 
have of the other muscles, as has been observed after diphtheria. 

We have constipation from causes interfering with chymification, — ■ 
from cancer and ulcer of the stomach, gastritis, acute or chronic, insuf- 
ficient alimentation, and improper food and drink — frequent causes in 
children — moral causes, physical suffering, vicissitudes of all sorts. — 
in a word, all causes of dyspepsia ; also from duodenitis, acute enteritis, 
fevers, intestinal dyspepsia, hepatitis, and cirrhosis of the liver, and 
catarrh of the bile-ducts. 

CONSTIPATION FROM MECHANICAL OBSTRUCTION FROM WITHIN. 

The introduction of foreign bodies, as worms, gall-stones, polypi, 
large haemorrhoids, and tumors of the rectum, invagination, volvulus, 
etc., diminished calibre of the intestines from hypertrophy of its coats 
or new growths, — these are among the causes of constipation. 

Pathology. — Constipation affects different children differently. 
The full-blooded and bilious child needs more frequent evacuations 



656 Acute and Chronic Constipation in Children. 

than the spare and anemic one. It seems to be clearly established that 
the retention of meconium will occasionally produce convulsions. 
Schlumberger cites cases which demonstrate this beyond any reasonable 
doubt. In infants we find constipation producing repeated attacks of 
colic, which may disappear without alarming symptoms if speedily 
relieved, but if long continued, bring about a swollen and distended con- 
dition of the bowels. 

Prolonged constipation in the young child produces disease in the 
caecum, — chronic inflammation, and in some cases induration and 
thickening; perforation of the intestines occasionally takes place. 
Among other serious consequences that sometimes occur are the different 
forms of hernia, varicocele, prolapse, fissure, catarrh of the bladder, 
spermatorrhoea, and especially haemorrhoids. The nerves in the pelvis 
may also be pressed upon by faecal matter, and disturbed sensibility, 
and pain or weakness in the lower limbs, will be the result. 

Chronic constipation with accumulations in the colon produces 
dyspnoea, also disturbances in the thoracic circulation. Palpitation, 
irregularity of the pulse, and vertigo frequently result ; and in anaemic 
girls we find rebellious headaches, hypochondria, and morbid thoughts. 
The same causes, when present in the lower part of the abdomen, pro- 
duce, in a few cases, difficult and frequent micturition. 

Habits of constipation due to neglect in school-days will frequently 
follow a patient for years, and have much to do with the production of 
chlorosis in girlhood. 

Symptoms. — Occasionally acute constipation will produce a con- 
dition which may jeopardize the health, if not the life of the child, but 
this is not usual. 

In a nursling a single evacuation each day, attended with strain- 
ing, is constipation, which, in many cases, inclines to become worse, 
until a movement of the bowels can be produced only by medicines or 
injections. The usual symptoms found in such a case would be the 
infrequency of evacuation, the slight hardening of the faeces, and the 
difficulty of their expulsion. Where a child is robust, and a proper 
amount of food is taken, and there is but a single passage daily, the 
symptoms are diminished appetite, increased volume and resonance of 
the abdomen, colicky pains, fulness, and a feeling of weight in the lower 
bowels. If this continues for another day, the face is flushed, the head 
somewhat hot, and the child nervous. In many young children we 
sometimes notice a pallor of the face, and rarely a jaundiced condition 
of the skin; indeed, a true jaundice sometimes supervenes from 
pressure on blood-vessels and consequent obstruction. From the condi- 
tion just mentioned the general nutrition of the child would suffer, and 
reflex action, such as convulsions, might ensue. Constipation in chil- 
dren under two years of age sometimes causes high fever with slight 
facial convulsions and grimaces which simulate nervous affections. 



Acute and Chronic Constipation in Children. 657 

In some forms of constipation there occasionally occurs a peculiar 
kind of diarrhea, produced as follows: The hard faeces, acting as a for- 
eign body, produce a more or less abundant fluid secretion, which finds 
a point of exit either between the faecal masses and the intestinal wall, 
or through a lumen dug out of the faecal accumulation. (Roche.) 
Thus an obstinate retention of immense masses of excrementitious stuff 
may be mistaken for, and treated as, a case of diarrhea. 

Along with other symptoms in older children, as heretofore 
described, with a distended abdomen there is furred tongue, hot mouth, 
offensive breath, headache, and sometimes vomiting, difficult breathing 
from abdominal distention, and in girls a condition is present which in 
after life may develop a misplaced uterus. Pain and uneasiness 
referred to the bladder are produced, and from this and other causes, 
bladder and kidney trouble have been suspected when only constipa- 
tion existed. In some children, also grown people, where constipation 
has become habitual, there is a change in the habits and character. 
Those fond of work and study can do nothing on account of a persistent 
headache, and while no physical signs of disease can be found, they are 
morose and melancholy. 

The constant bearing down which is present in chronic constipa- 
tion may produce hernia, haemorrhoids, fissures, and other symptoms 
referable to the rectum. 

Stubborn constipation may give rise to faecal accumulations and 
symptoms of intussusception. Marmaduke Shields narrates a case in 
which motions "like pebbles" were passed ; then came incessant vomit- 
ing, discharge of blood and mucus from the bowels, and prolapse. 
Syncope occurred, with profuse sweating, and death seemed imminent. 
At this time a hard, irregular swelling in the left lumbar region was 
discovered, and an examintion per rectum established the diagnosis of 
accumulation and impaction. 

Diagnosis. — It should always be remembered that a small amount 
of faecal matter evacuated by a child whose alimentation is sufficient as 
regards quantity, should not be regarded as indicating constipation. In 
the acute variety there will be infrequency of normal passages from the 
bowels, pain upon pressure of the abdomen, accumulation of gas, a 
coated tongue, and a hot mouth. 

Prognosis. — The prognosis is always regarded as good ; also the 
prognosis in chronic constipation is regarded good as to life ; but locally 
it produces diseases of the rectum, haemorrhoids, fissures, and hernia. 
In some cases such a degree of stenosis is produced that the most 
serious results are anticipated, and laparotomies have been performed 
with the expectation of finding intussusception, etc. To avoid such 
mistakes, a very large injection of warm water should be administered 
in the recumbent position, or insufflation of air should be made before 
the operation is commenced. 

42 



658 Acute and Chronic Constipation in Children. 

Treatment. — The number of drugs administered to infants, chil- 
dren, and adults, is surprising, if not alarming. Castor-oil, gray 
powder, calomel, senna, aloes, scammony, jalap, podophyllin, bella- 
donna, rhubarb, cascara — besides the favorite powders of different 
doctors — are all given in various combinations. For the nursling, 
except in an emergency, they are useless, and should not be given. The 
indications are to correct the condition either by attention to the mother 
or by a slight change in the food of the child, and to avoid laxatives. 

After excluding congenital defects, we must look to the mother 
for the cause. If an evacuation of the bowels does not occur within 
twenty-four or thirty-six hours after birth, a careful examination of the 
anal opening should be made ; in some of the large lying-in hospitals 
a very small enema is given as a part of the baby toilet at the first dress- 
ing. This demonstrates at once the perviousness of the canal. Change 
the mother's diet ; thereby you will correct the constipation of the 
infant. It may be necessary to administer a mild laxative to the 
mother ; for, as a rule, simple constipation in the child should be over- 
come without giving it medicines or injections. If a child has been 
provided with a wet-nurse and is constipated, the question will arise as 
to the propriety of changing to a wet-nurse with younger milk in order 
to furnish more colostrum and less casein. Everything of a constipat- 
ing nature, including starchy foods, is to be excluded from the diet of 
mothers or wet-nurses when the infants are constipated. 

If these directions are followed, and yet the habit persists, and the 
child has but a single dry passage each day, and this is attended with 
straining, some very simple remedies may be given. The most simple 
laxative for a new-born infant is a little molasses — New Orleans 
molasses seems to act best — a teaspoonful in a little warm water admin- 
istered when needed. When the passages are very dry, and the child 
is known to perspire freely, we should suspect an insufficiency of water in 
its system, and to overcome this there is nothing better than pure water 
internally. As a rule, babies are much neglected in this respect. All 
babies should have water daily ; it is an infliction to deprive a child of 
water; the deprivation is not only a cause of constipation, but some- 
times of absolute suffering on the part of the child. A baby is not 
always hungry when it cries, it is often thirsty. To feed it when it is 
only thirsty, and not give it the water it craves, will sometimes aggra- 
vate constipation. Remember, then, that one of the most efficient rem- 
edies in the treatment of children is water given three or four times 
during the twenty-four hours. To a child accustomed to a mixed diet, 
in place of water oatmeal water may be given for a time, in order that 
the child may be nursed less frequently. 

If the measures already suggested do not give relief, of course 
other treatment must be adopted, and we come to consider local stim- 
ulants w T hich may be introduced into the rectum. Soap, glutin, or 
glycerine suppositories are suggested; molasses candy molded into lit- 



Acute and Chronic Constipation in Children. 659 

tie masses and introduced, and injections of very small quantities of 
glycerine and water, the nozzle of the syringe being oiled before inser- 
tion. Bohn recommends injections of cold water three times a day if 
needed, then twice a day, and finally once a day until the cure is 
assured. Other writers recommend - a little common salt added to the 
cold water. 

If enemata are necessary, either warm or cold, small quantities 
must be used, one or two teaspoonfuls of water, with perhaps ten to 
twenty drops of glycerine added, being considered very efficient. Large 
injections of any fluid should be avoided, not only because they dilate 
the colon and paralyze the lower bowel, but because they are liable to 
produce discomfort in the infant by crowding against other internal 
organs, producing difficult respiration and interference with circula- 
tion. In the case of a few infants, growth and nutrition seem to 
progress naturally in every respect, with but a single passage each day, 
and with such it is not necessary to interfere. If drugs must be given 
to the nursling, nothing will yield better results than minute doses of 
calomel, or small doses of castor-oil, or of magnesium carbonate, grs. x 
to xv to 3 i of water and syrup, given in teaspoonful doses as needed ; or 
a grain or two of the magnesia may be given in a little sweet milk. 

In older children we should endeavor to inculcate the habit of 
regularity by seeing that attempts to evacuate the bowels are made. 
In all cases the constipation should be removed : but let there be a 
cooperation of habit, expectation, and will, with laxative foods, before 
we resort to drugs. Teach older children that they must go to the closet 
every morning; just after breakfast is an important time to form the 
habit of having a natural movement. Mothers should be watchful of 
their children from birth till the child is old enough to attend to itself. 
In children one, two, and three years old, massage and irrigation of the 
bowels are very useful, being much better than suppositories, soap in 
particular tending to irritate the bowels and produce local inflam- 
mations. 

Children on a mixed diet should avoid the starchy foods and eat 
more soups and drink water freely; let the food be somewhat coarse, 
well masticated, and swallowed slowly, and avoid giving the same food 
repeatedly. If the digestion is good, more milk may be added to the 
food; a little oatmeal will increase its coarseness, and a few drops of 
molasses make it slightly laxative. This may be changed from day to 
day to mush made from unbolted wheat-flour, or cornmeal, or to bran 
in bread and milk, prepared by soaking the bran in the milk, warming, 
and then adding the bread. Whey, when it can be obtained, is of great 
benefit. Children who are two or three years of age may be given 
stewed fruits or baked apples. Small quantities of fruit, particularly 
grapes without skin or seed, and figs and dates, are useful. At the age 
of three and upwards, we advise home gymnastics, swimming, and salt 
bathing. 



660 Acute and Chronic Constipation in Children. 

Children, as well as grown people, invariably bear calomel in but 
small doses; it should be given in one-twentieth down to one-tenth or 
to one-fourth, according to age ; it may be given every hour till four or 
six doses are given ; then follow by a little magnesium next morning to 
move off the calomel if needed. Calomel is not recommended in 
rachitic diathesis. Castor-oil paste, made by rubbing together powdered 
acacia, castor-oil, syrup, and glycerine, and flavoring with anise or 
vanilla; or gray powder with a little bicarbonate of sodium, or pow- 
dered liquorice (pulv. glyccyrrh, comp.) with sulphur, may be admin- 
istered to rachitic patients. The small doses of belladonna and mix 
vomica will be found a combination very serviceable in giving tone to 
the bowels or for relieving spasms. Magnesia and asafoetida are espe- 
cially useful in relieving the distressing symptoms of gas or flatus. 

The family physician should see to it that the older children do 
not eat those articles which are known to constipate; forbid spices, 
cheese, dried fruits, and the coarser dry foods. Medicine should not be 
employed for failure to evacuate the bowels every day, but attempts 
should be made to remove constipation by attention to diet, rubbing the 
abdomen, and the use of moderate exercise. If drugs must be taken, 
find the one which agrees with the patient, and then the dose which is 
suited to the case ; then gradually reduce the quantity of medicine till 
the diet, which has been corrected, keeps the bowels in a normal con- 
dition. The fluid extract cascara sagrada, in doses of one or two drops, 
will be found an excellent remedy. For a child of two years, clear out 
the bowels with a powder containing one-half to one and one-half grains 
of calomel with a little compound liquorice powder ; follow for a few 
days with carbonate of magnesium (5ii to water ^j ) give one to three 
teaspoonf uls each day till the bowels are relaxed. Then give non- 
astringent iron preparations or mix vomica. Dr. H. H. Clark recom- 
mends especially small doses of calomel, and one-twentieth of a grain to 
one-halfor one-grain doses of ipecac, as the remedy for constipation in 
children. 

The headache and coated tongue, the nervous and feverish symp- 
toms, with dizziness, which we find associated with constipation and 
possible diagnosed as biliousness and indigestion, can not easily be 
cured by neurotic remedies. First clear the bowels (this applies to 
adults) of their accumulated filth, then give a remedy to act on the 
secretions, such as calomel, gray powder, and afterwards give iron, nux 
vomica, and magnesia. 

The galvanic current of electricity alternately with the faradic 
current is very beneficial in aiding the removal of constipation. Sev- 
eral portions of the bowels respond differently to the application of the 
faradic and galvanic current. The galvanic is usually the stronger. 
Local contraction results from the negative pole, peristaltic waves from 
the positive. Apply the negative pole in the rectum and the positive 
over the abdomen along the colon. By gentle massage or kneading of 



Acute and Chronic Constipation in Children. 661 

the abdomen over the colon and in the direction of its peristaltic movt- 
nients, muscular action is stimulated and the desired results are fre- 
quently brought about. This process should be repeated two or three 
times a day. Cod-liver oil and syrup of the iodide of iron are espe- 
cially useful in the rickety and strumous diatheses. 

Children with indigestion associated with constipation should 
always have first a corrected diet, then pepsin in combination with 
muriatic or hydrochloric acid, and cascara or compound syrup of 
taraxacum. 

There are cases where the accumulations of faecal matter must be 
removed by the more powerful cathartics and by regular irrigation, 
which sometimes must be carried into or through the mass by means of 
a tube. 

An impacted rectum must be cleaned by the use of the syringe, 
and occasional digital assistance will be required. 



CHAPTER LIV. 

PAEASITES OF THE INTESTINAL CANAL, AND DIS- 
EASES DUE TO PARASITES. 

As a rule, the animal parasites which find their way into the 
human system, enter the body in the food or drink, and either remain 
permanently in the intestinal canal, or, migrating from this region, 
are to be found in the remotest parts of the body ; while other parasites 
infest the skin, are capable of extensive migration, and produce sim- 
ply local disturbance. (Molsler and Piepes.) 

The varieties of verminous parasites found in man are the tape- 
worm, the flukes, the leeches, and the round and threadworm. 

TAPEWORM, OR CESTOID. 

This parasite includes the several varieties of taenia, or tapeworm, 
which prove injurious to man by their presence in the intestines, and 
especially by their occurrence in the larval stage in the various organs 
and tissues of the body. From the mature worm which lives in the 
intestines of man or of a lower animal, are discharged eggs, either 
free or included within the segments. If these eggs are swallowed by 
man or by different lower animals, the envelopes are digested and the 
embryos set free. The latter penetrate the walls of the blood-vessels 
and lymphatics, and are then carried to various parts of the body, in 
which their development into cysts, — the cysterci, — takes place. 
These cysts are the larvre of the tapeworm, and when swallowed become 
the tapeworm. Taenia solium and taenia saginata most frequently 
occur in man. 

Taenia Solium,. — The pork tapeworm, six to nine feet long, has 
a round head the size of a pin-head, armed with twenty-six hooklets 
in a double row, rising from a pigmented base, and provided with four 
suckers. The narrow neck soon becomes transversely lined, an indica- 
tion of the formation of segments, which, some three or four feet from 
the head, are square instead of being elongated. In the fully-developed 
segments from the four hundred and fiftieth downward, both the male 
and the female generative organs are found, and the uterus is readily 
seen, on pressure of the proglottid between plates of glass, as an 
arborescent figure with a central trunk, from each side of which pro- 
ject eight or ten lateral branches. After the tapeworm has been in 
the intestines for three or four months, the mature segment, nine to 
ten millimeters long and six to seven millimeters wide, may be found 
in the stools. From the eggs taken into the stomach of man. swine, 
(662) 



Parasites. 663 

sheep, dogs, and rats, is developed the Cysticuercus cellulosae, to be 
found in the various parts of the body ; in hogs the condition thus pro- 
duced is called measles. 

The Taenia solium lives in the middle of the small intestines, to 
the walls of which it clings by its hooklets, and may remain alive for 
several days after the death of a patient. Although usually found 
alone, several may be present, and Kleefeld observed forty-one in the 
same individual. The Taenia solium is very common in central Ger- 
many, where raw or insufficiently cooked pork is often eaten; and 
from one-third to one-half of the patients seeking hospital aid for 
various causes are said to be affected with this parasite. (Wood.) 

In regions in which pork is but little eaten, or in which the cook- 
ing or various methods of its preparation have destroyed the vitality 
of the eggs, the tapeworm is comparatively uncommon. 

Taenia saginata, the beef tapeworm, is twelve to twenty-four feet 
long, and has a square pigmental head as large as that of a pin, pro- 
vided with four suckers, but has no hooklets. 

The Taenia saginata clings to the wall of the small intestine by 
means of its suckers, and abounds in those countries in which beef is 
the chief article of animal food. It is, therefore, the common tape- 
worm of the United States. Its propagation in man is dependent upon 
the use of raw or insufficiently cooked beef. 

The Taenia elliptica has been found in infants and young chil- 
dren, but abounds in dogs and cats, the embryo being harbored in lice 
and fleas. The Taenia nana has also been repeatedly found in children. 

The Bothriocephalus latus, or fish tapeworm, is from fifteen to 
twenty-seven feet long, and has a club-shaped head, without suckers 
or hooklets, but provided with two lateral grooves. The proglottides 
are broad and short. The eggs escape into the intestines from the ripe 
segments, and are further developed in water. They are swallowed 
by the pike, perch, salmon, and turbot, in the flesh and viscera of which, 
according to Braun, the embryos are found, and from which the mature 
worms have developed in dogs and cats as well as in man. It is said 
that in regions where improperly cured fish is eaten, especially along 
the Baltic and in Bavaria and Switzerland, this worm abounds. Odier 
states that in Geneva twenty-five per cent of the population harbors this 
parasite. 

Etiology. — The tapeworm of man, according to the variety, is 
derived from raw or insufficiently cooked beef, pork, or fish. It is 
more frequently found in men than in women, and abounds during 
the middle third of life, although common among children, and Men- 
singa found it in an infant of ten weeks. Molsler and Peiper state 
that butchers, inn-keepers, waiters, cooks, and housemaids are especially 
apt to be affected. 

Symptoms. — The parasite, according to history, may be harbored 
for years, especially by robust individuals, without producing any dis- 



664 Parasites. 

turbance, but sensitive persons, particularly women, are likely to suffer 
various symptoms, especially after the existence of the tapeworm has 
been discovered. Even before its presence is recognized, such persons 
may be anemic, easily tired, and subject to digestive derangements. 
The appetite often becomes feeble or capricious, but more frequently is 
excessive. Nausea, vomiting, and the regurgitation of gas and a bitter 
or acid fluid, occur. Attacks of colic arise without apparent cause; 
existing diarrhea or constipation is often attributed to the movements 
of the worm, which are frequently asserted to be aggravated by certain 
kinds of food, and assuaged by agreeable articles of diet. Women who 
have borne children have stated that the movements of the tapeworm 
in the bowels resemble those of the foetus in the uterus. 

Numerous disturbances of the nervous system are attributed to 
the parasite, and are regarded as of a reflex nature; such are mental 
and physical sluggishness, often suggesting melancholia and hypo- 
chondriasis, while vertigo, fainting, disturbances of sight and hearing, 
irregular pupils, hiccough, cramps, and convulsions are said to be 
caused by the tapeworm, and often disappear when the parasite is 
removed. 

The Bothriocephalus latus, in particular, has been frequently 
found in persons showing a marked degree of anaemia. Palpitation, 
dyspnoea, loss of flesh and strength, and perhaps fever, may be so 
severe as to confine the patient to bed, and dropsy may be present. The 
resemblance of these symptoms to those of progressive pernicious 
anaemia is intimate, and in certain cases they are relieved by the expul- 
sion of the parasite, while in others improvement does not follow. 

The tapeworm is usually discovered by observing segments in the 
stools, although the segments may escape from the bowel at other times 
than during defecation, and then attract attention by the associated 
itching near the anus, or by the sensation of a smooth and slippery body 
upon the skin of the buttocks or thigh. They have escaped through 
the abdominal wall from intestinal fistulae, have been voided with the 
urine in cases of vesicointestinal fistulae, and have been vomited. The 
tapeworm may exist for years, and the passage of segments be observed 
only at rare intervals. Their evacuation is said to be promoted by a 
diet containing fruit, and salted, pickled, or spiced articles of food. 

Diagnosis. — The presence of tapeworm in the intestines is to be 
recognized only by the discovery of the segments or of the eggs, and 
their evacuation may be promoted by the use of a brisk cathartic. 

Prognosis. — Tapeworms are rarely dangerous to their host, the 
beef-worm being the least harmful. The Taenia solium, or pork tape- 
worm, may become dangerous if its mature segments enter the stom- 
ach during a reversal of intestinal peristalsis, and become digested, 
since the embryos are then set free and may become cysticerci. The 
Bothriocephalus latus may prove a source of profound anaemia. 

Treatment. — The chief drugs used against the tapeworm are 



Parasites. 665 

pumpkin seeds, the oleoresin of male fern, pomegranate rind and its 
alkaloids, pelletierine, and isopelletierine, kousso, and its active prin- 
ciple, tseniin or koussin, turpentine, and thymol. Whatever the drug- 
selected, it is necessary to see that the intestinal canal is as free as may 
be from contents which might protect the worm. The patient should 
take a brisk cathartic thirty-six hours before the anthelminthic, be put. 
on milk diet for twenty-four hours, and left entirely without food dur- 
ing the morning of giving the anthelminthic. We have usually 
employed pumpkin seed (pepo). Two ounces of it may be made up 
in an electuary with sugar and aromatics. Having on Sunday night 
taken a cathartic and on Monday no food but milk, and none of that 
after six o'clock in the evening, the patient should on Tuesday morn- 
ing breakfast on the pumpkin seed prepared as above, with, if desired, 
a cup of coffee or tea. Three hours afterward he should take half an 
ounce of castor-oil with two drams of oil of turpentine. If the patient 
is feeble, the turpentine may be omitted. Purging will usually come 
on in two or three hours, afld at this time about a quart of saturated 
watery solution of ordinary salt should be thrown into the large intes- 
tines to aid in the expulsion of the worm. In a robust, obstinate case, 
one-half to one dram of the oleoresin of fern may be taken two hours 
after the ingestion of the pumpkin seed, and followed in two hours by 
castor-oil. 

Pomegranate rind is highly recommended as an efficient vermifuge ; 
the bark that comes in small, thin quills is believed to be more active 
than that in larger pieces. The decoction may be made by boiling two 
ounces of the bruised drug, after maceration, for twenty-four hours, in 
two pints of water to one pint. A wine-glass of this should be taken 
every half hour until the whole has been taken, or until violent purg- 
ing has been produced. If purging does not occur, the last dose should 
be followed shortly by castor-oil. The alkaloids of pomegranate are 
chiefly used in the form of a tannate ; as put on the market by Tanret, 
their discoverer, each contains about five grains, one dose. The dose 
of pelletierine tannate, as furnished by Merck, is set down as at from 
eight to twenty-four grains in an ounce of water, to be followed in 
an hour by a brisk cathartic. Taeniin is stated by European writers 
to be efficient when given in doses of from twenty to forty grains,' and 
in two hours followed by a carthartic. 

Of the tsenicides just mentioned, pepo, or pumpkin seed, so far 
as known, is harmless to man. The use of the oleoresin of male fern 
is reported to have caused several deaths. 

Cysticercus Disease. — This affection is due to the presence in the 
body of the Cysticercus cellulosae, the larval stage of the pork tape- 
worm, resulting from the entrance of the ova of the Taenia solium into 
the stomach. The Cysticerci occur oftener in men than in women, 
usually in middle life. The Cysticercus, once lodged, usually remains 
fixed, although when the movements of its head have been observed 



666 Parasites. 

with the ophthalmoscope, it is considered that migration is possible, 
provided there is no mechanical obstruction. According to Dressel, 
the organ in which they are most often found is the brain, usually in 
the membranes and cortex, especially in the fissure of Sylvius They 
have been observed in eighty cases by Von Graef e, and have been found 
in the heart, lungs, liver, kidneys, and bones. 

Symptoms. — There may be numerous Cysticerci in the body, and 
no resulting disturbance be felt, or a single Cysticercus may rise to the 
severest symptoms. Invasion of the brain and cord is more likely 
to produce disturbance than of the skin and muscles, although in the 
former there may be but a single cyst and in the latter innumerable 
cysts may be present. 

Diagnosis. — The presence of Cysticercus is recognized by the dis- 
covery of the parasite, when it is seen in the eye or found in a tumor 
removed from the skin or muscle. 

Prognosis and Treatment. — Cysticerci may be inconvenient in the 
muscles or skin, but are a source of danger only when in the heart and 
brain. The only radical treatment is surgical. (Wood.'* 

ECHINOCOCCUS DISEASE, OR HYDATIDS. 

The echinococcus, or hydatid, is the larva, or egg, of the Taeni 
echinococcus , a tapeworm of the dog, wolf, jackal, and fox, and is rarely 
found in man in this country. The disease abounds in countries in 
which dogs are numerous, as in Australia and Iceland. 

Symptoms. — It is said that the invasion of the embryos often 
causes no known symptoms. When symptoms occur, they are due to 
the pressure of cysts upon surrounding parts, to their rupture, or to 
the suppuration of their capsules, and their severity varies largely with 
the size and seat of the cyst and the organ concerned. The large 
hydatid of the liver may produce but little disturbance, while a small cyst 
in the brain may rapidly prove fatal ; cysts pressing on the spinal cord 
cause paralysis, and hydatid of the bone leads to a spontaneous frac- 
ture. When perforation of the capsule takes place, the contents of 
the cyst may escape into the alimentary canal, into the uro-genital 
tract, into the bronchi, or through the skin. 

Suppuration of the fibrous capsule of the cyst results in the forma- 
tion of abscesses, which are manifested by chills, fever, localized pain, 
progressive emaciation, debility, and perhaps jaundice. Death from 
pyemia or septicemia is the frequent result. 

The general symptoms are associated with the presence of a tumor, 
sometimes larger than a man's head, flat on percussion, and when tangi- 
ble, usually sharply defined, rounded, smooth, elastic, fluctuating, and 
sometimes presenting a thrill suggestive of quivering jelly. A sim- 
ilar sensation is sometimes obtained from ascytic fluid or from the con- 
tents of an ovarian cyst ; hence this hydatid thrill is of no very special 
importance. 



Parasites. 667 

Echinococci of the nervous system produce symptoms such as are 
caused by similarly-located tumors ; in the lungs they produce no symp- 
toms until they attain a size sufficient to cause compression of the 
lungs or perforation of a bronchus, when inflammation, gangrene, and 
empyema may arise. When the cyst ruptures into the pleural cavity, 
there are sudden pain and dyspnoea, and sometimes uticaria ; pleurisy 
is the constant outcome. Perforation of the pulmonary vessels has led 
to embolism and fatal hemorrhage. The growth of the pulmonary 
echinococcus may be manifested by cough, pain from associated pleu- 
risy, dyspnoea, fever, and emaciation, symptoms suggestive of phthisis. 
When the echinococcus is in the upper lobe, there may be haemoptysis 
and signs of consolidation, and yet the nutrition of the patient remain 
undisturbed. The absence of characteristic bacilli becomes important 
in differential diagnosis, although tuberculosis and echinococcus may 
coexist. 

When echinococci develop in the pleural cavity, the symptoms 
resemble those of hydro-thorax, and there are displacement of the heart 
and diaphragm and retraction of the lungs corresponding to the size of 
the cyst. 

ECHINOCOCCUS OF THE LIVER. 

When hydatids of the liver are of a size sufficient to produce symp- 
toms, enlargement of the organ results, either local or general, and the 
cyst may project from the surface as a rounded tumor, or the bound- 
aries of the liver may extend from the second rib to the crest of the 
ilium. A sensation of weight and pressure in the epigastrium and 
right hypochondrium may be present, and the upward displacement of 
the diaphragm may cause dislocation of the heart, compression of the 
lung, and dyspnoea. Pressure upon the portal veins produces ascites, 
while, if the hepatic vein or the inferior vena cava is compressed, 
oedema of the legs results. 

Echinococcus of the liver is to be diagnosticated by the recognition 
of the enlargement, usually circumscribed, of this organ, and the deter- 
mination of its cause by means of the aspirator. For a long time the 
strength and nutrition of the patient are well preserved ; hence amyloid 
degeneration and cancer are easily excluded, and the persistent jaundice 
of hypertrophic cirrhosis is lacking. An echinococcus projecting from 
the upper surface of the liver may resemble a pleuritic exudation, but 
the highest point of dulness from the latter is in the dorsal and not in 
the axillary region. 

ECHINOCOCCUS OF THE KIDNEY. 

The parasite occurs more often in the left kidney, and its growth 
tends to produce a cystic tumor sometimes of large size. The general 
health is unaffected, and special symptoms are usually delayed until 
perforation of the walls of the cyst, with escape of the contents, takes 



668 Parasites. 

place. The physical examination of the tumor gives evidence of its 
cystic nature, and its renal origin is determined by its position behind 
the colon and by its immobility. 

ECHINOCOCCT OF THE PERITONEUM. 

The echinococcus may lie free in the peritoneal cavity, but it is 
more commonly situated in the subperitoneal tissue, especially in the 
omentum and mesentery and in the wall of the pelvis. Hundreds of 
cysts may be present, resulting in abdominal tumors of large size. The 
growth is gradual, and usually without symptoms, until the movements 
o£ the diaphragm are interfered with, when respiration is disturbed, 
or the stomach and bowels are compressed or united by adhesions, with 
corresponding impairment of functions. 

Childbirth, we see reported, has been delayed and retention of 
urine produced, when echinococci were in the pelvis, while extensive 
suppuration and death from septicemia have followed perforation into 
the intestines or the vagina, although the passage of peritoneal echino- 
cocci into the hollow organs is rare. The physical examination of the 
enlarged abdomen is indicative of the presence of fluid, while the grad- 
ual enlargement and absence of symptoms are suggestive of the presence 
of an ovarian cyst. 

Diagnosis. — The diagnosis ultimately depends upon the recogni- 
tion of the tumor, which is of slow growth, usually painless, and gen- 
erally without disturbance of nutrition. 

Treatment. — Whenever the cyst becomes a source of discomfort, 
its treatment by aspiration or removal becomes necessary. Aspiration 
has been frequently followed by complete cure, but is somewhat dan- 
gerous and may prove ineffectual in retarding the growth of the cyst. 
Of late years cysts and complicating abscesses are being repeatedly 
opened, evacuated, and drained, with, as a rule, favorable results. 
(Wood.) 

FLUKES. 

Among the trematoid worms dangerous to man, of especial impor- 
tance are the blood-flukes, lung-flukes, and liver-flukes. 

The distoma hsemotobium, or blood-fluke, was discovered by Bil- 
harz and Griesinger in the portal system and in the recto- vesical plexus. 
The eggs are present as small white specks in the liver, in the intestinal 
wall, and especially in the urinary tract. It is supposed to live in the 
waters of the Nile, and Europeans who use filtered water rarely become 
diseased. The presence of the parasites in the mucous membrane of 
the bladder and ureters causes a hemorrhagic inflammation of the 
mucous membrane, within and upon which the eggs are to be found, 
having escaped from the blood-vessels. Xerotic patches infiltrated with 
urinary salts are to be seen upon the surface of the membrane, and 
pyelitis and nephritis may be associated. Rectal and vesical tenesmus, 



Parasites. 669 

painful micturition, intermittent hamiaturia, increased on exertion, 
hypogastric tenderness, progressive anaemia, and loss of flesh and 
strength, result. 

Diagnosis. — The diagnosis is based upon the discovery of the eggs 
of the parasite, which are present in large quantities, chiefly in the 
blood-clots and slime in the sediment of the urine of persons suffering 
from cystitis and hematuria in the regions in which the parasite are 
found. Medical treatment is only palliative, and consists in meeting 
symptoms as they arise. 

BOUND AND THREAD WORMS. 

Of the nematoid worms parasitic in children, one of the most 
common is the ascarides lumbricoides. These, next to the trichoce- 
phalusdispar, are most harmless. They resemble the earth-worm, are 
long, cylindrical, yellowish or reddish yellow, pointed at both ends. 
They are to be found in persons of all ages. The eggs are probably 
swallowed in drinking water. These worms live in the small intes- 
tines ; their bodies are marked by four longitudinal dark bands, and 
are striated transversely. At the head are three rounded elevations, 
and between these a number of fine teeth. The length of the male is 
from four to seven inches, and the female from six to eleven inches. 

Symptoms. — The most varied symptoms are given as due to the 
presence of these worms. It is true that in some children, even when 
worms are present in considerable numbers, no symptoms are produced. 
There may be vague and unpleasant sensations in the umbilical regions, 
which may increase to colicky pains. Sometimes there is more or less 
dull continuous pain, becoming at times more severe. The abdomen is 
often swollen, the appetite is capricious, and there may be nausea and 
vomiting. Mucous diarrhea is sometimes present ; many of the symp- 
toms which are much regarded by the laity, such as itching and piekiug 
ar the nose, are considered by some writers of no importance. Chil- 
dren who are weakly, and in whom the worms are present in great num- 
bers, may lose flesh and become pale. Various nervous symptoms, such 
as grinding of the teeth, unquiet sleep, disturbance of sensation, widen- 
ing of the pupils, reflex convulsions, are some of the most common in 
young children. In the tropics the symptoms produced by worms are 
more severe ; this is due to the enormous numbers which are present. 

It is always serious when the worm ascends the intestines to the 
pharynx. It produces severe paroxysms of coughing, a feeling of suf- 
focation, pain in the region of the larynx, and frequently a quickly-fatal 
asphyxia. If it passes the larynx and enters the trachea, the symptoms 
become milder. There are still violent coughing, hoarseness, or even 
aphonia, pain in the breast, vomiting, and convulsions. If it is not 
expelled by fits of coughing, death takes place in from one to three 
days, generally from gangrene of the lung. It is said not to be uncom- 
mon at autopsies to find a worm in the pharynx or larynx, it having 
crawled there after the death of the individual. 



670 Parasites. 

Diagnosis. — This must always be made from finding the worms 
or the eggs in the feces. The eggs are often present in large numbers, 
and can be easily recognized. In looking for the eggs it is best to give 
a purgative, then filter the liquid stools and examine the solid residue 
microscopically. 

Prognosis. — The prognosis is favorable. Unless the parasites are 
in enormous numbers, they do not produce dangerous conditions; but 
there is always some danger that they will wander into some other part, 
produce suffocation by entering the air passages, or set up a purulent 
hepatitis by entering the bile-duct. 

Treatment. — The remedy on which the most reliance can be placed 
is santonin and pepo. Santonin is almost devoid of taste and smell. 
It may be given mixed with a little sugar in doses of from one-fourth 
to one grain according to age. It is better to give it mixed with a little 
calomel, two hours apart, till three doses are administered. 

li Santonin gr. j 

Calomel gr. J 

Sugar gr. vi 

M. ft. chart No. 3. 

For a child of ten years the above is to be given at four, six, and 
eight o'clock p. m., and followed the next morning by a dose of Epsom 
salts or castor-oil. The dose should be repeated every ten days for 
two or three times, till all the eggs or young worms have been expelled. 

Pumpkin seeds (pepo) are prepared in two ways; the hull is 
taken from the seeds, and the pulp rubbed with water to a thick 
mass. Of this may be given one or two ounces in a single dose. 
Should the worms not be expelled, the dose may be repeated several 
nights if necessary. 

The author has had excellent results from the use of pepo pre- 
pared as follows: Beat well in a mortar one pint of pumpkin seed 
with the hulls on; put three pints of boiling water over the seed in 
a covered vessel ; set it on the back of the stove, let it simmer down 
to one pint, strain through a cloth, and squeeze the mass to express 
the oil; divide the tea into three equal parts. The day previous to 
the treatment, the bowels should be moved with a dose of Epsom 
or Kochelle salts, a light supper of bread or crackers and milk be 
given, and no breakfast allowed till after the pumpkin-seed tea has 
been administered. Give the first dose at six, the next at eight, and 
the next at ten o'clock; at twelve o'clock give a dose of castor-oil; 
at two p. m. if the oil has not moved the bowels, give a dose of Epsom 
salts. The pumpkin-seed tea may be given every ten days for three 
times. The above is for an adult; a child of ten takes half, and 
one of five, one-third the quantity for a dose. 



Parasites. 67 J 



PI2n t -W0R^IS. 



The Oxyuria vermicularis, known as seat-worms or pin-worms, 
produce very unpleasant symptoms. The male is much smaller than 
the female, ranging in length from one-twelfth to one-sixth of an 
inch; the female is from one-fourth to one-half of an inch in length. 

The whole course of development takes place in the intestines. 
As soon as the worm is freed from its egg, it wanders into the lower 
portion of the intestines. Here it grows quickly, and then descends 
into the lower part of the small intestines, where conception is effected. 
The eggs are deposited in the rectum partly in the mucus and 
partly on the mucous membrane. The development of the worm is 
rapid. Leuckart and three of his scholars swallowed the eggs, and 
found young embryos in the stools fifteen days afterward. The worms 
are also propagated by self-infection. They get on the fingers or 
beneath the nails from the efforts wkich the patients make to allay 
the intolerable itching in the neighborhood of the anus ; in this way 
they are often conveyed to the mouth. Children, especially, are apt 
to reinfect themselves in this manner. 

Symptoms. — They may be present without producing any symp- 
toms. Ordinarily they produce a chronic irritation of the rectum, 
with itching, burning, and pain, which extend to the external geni- 
tals. In the evening, and especially at night after the patient has 
become warm in bed, the worms seem to be in their most excitable 
condition, and cause various unpleasant symptoms. The symptoms 
often return each night with the utmost regularity. In children, 
especially, various sympathetic nervous symptoms, such as restlessness, 
itching of the nose, involuntary twitchings, grinding of the teeth 
during sleep, chorea, convulsions, and even epileptiform seizures, may 
result. The itching and burning of the genitals may lead in both 
sexes to onanism. In young female children, pruritus and leucorrhoea 
are sometimes seen, and in those _ approaching the age of puberty, 
various forms of hysteria. There is often a marked anemia, but 
instead of anorexia, there may be a ravenous appetite, especially in 
children. If the condition has lasted a long time, the stools are rather 
soft, of a fetid odor, and mixed with mucus. 2s"ot only do the worms 
pass out in the stools, but they also creep out spontaneously, and an 
investigation of the anal regions will often reveal them in the folds 
around the anus. In female children they may enter the vagina and 
here set up a purulent inflammation. Within the anus the mucous 
membrane is swollen, deeply injected, and covered with mucus, which 
is often tinged with blood. 

Diagnosis. — On inspection of the anal region, the worms will often 
be seen, though they are sometimes so small as to easily evade observa- 
tion. By washing out the rectum with cold water and examining it, 
they will always be found if present. The eggs may be recognized, 
on microscopical examination, by their long oval form. 



672 Parasites. 

Prognosis. — There are no really dangerous conditions produced 
by the Oxyuris; but the condition is unpleasant, and it is often diffi- 
cult to remove them successfully. 

Treatment.- — First, give a cathartic to move the bowels; let the 
patient eat a light supper, take no breakfast but pumpkin-seed tea, 
as already prescribed for the lumbricoid worms. The next morning 
after taking the pumpkin-seed tea, let the patient wash out the rectum 
with an infusion made from quassia chips; inject about half a cup 
of the infusion* and retain it ten or fifteen minutes, then eject it; 
then inject sulphur ointment with a salve injector, which can be 
obtained from any first-class drug store or from any surgical instru- 
ment dealer. 

The quassia decoction is made by boiling two quarts of water with 
two ounces of quassia chips to one quart, in an earthen vessel; for 
a child two or three years old, two tablespoonfuls should be injected 
every morning, after first washing out the rectum with warm salt 
water; then after waiting a few minutes, inject a little of the decoc- 
tion; in about an hour inject the sulphur ointment, enough to anoint 
the rectum thoroughly. For older children the amount of the infu- 
sion of quassia may be doubled ; if it does not come away in fifteen 
minutes, inject a little warm salt water to remove it before using the 
ointment. 

TRICHINAE. 

This is the most dangerous of the worm parasites, although the 
real danger is not connected with the presence of the adult worm in 
the intestinal canal, but with the embryonic condition, in which the 
parasites invade the voluntary muscles. The embryos are frequent 
in the muscles of pigs ; and from eating flesh containing them in an 
imperfectly cooked or raw condition, infection takes place in man. 
When introduced into the stomach, the embryos increase in size and 
mature in two or three days. They produce an astonishing number 
of young, estimated by various authors to be from two hundred to 
one thousand. These penetrate the mucous membrane, and in a short 
time find their way to the different muscles of the body. 

Symptoms. — Trichina? produce more or less gastro-intestinal 
catarrh; even small ulcers in the duodenum are caused by them. 

There are two groups of symptoms, — those caused by the worms 
in the intestinal canal, and those caused by the presence of the embryos 
in the muscles. Those in the intestines are due principally to the 
perforations of the wall. When it is considered that the number of 
these perforations may reach into thousands, it can easily be seen 
that notable disturbances may be produced. These are shown by 
diarrhea, abdominal pains, and vomiting. There are generally loss 
of appetite, malaise, weakness, headache, and unquiet sleep. The sec- 
ondary symptoms are intense pain and inability to move. Consti- 
tutional symptoms accompany both conditions, and often simulate those 



Parasites. 673 

of typhoid fever. Death takes place from exhaustion, and is often 
preceded by coma. 

Prognosis. — The prognosis depends almost entirely upon the num- 
ber of embryos which are generated in the intestinal canal. When 
a great number are present, the disease is almost necessarily fatal. 
If not fatal, the symptoms slowly subside; the worms in the mus- 
cles become encysted, and thenceforth are quiescent. 

Treatment. — The only time when treatment is efficacious is when 
the mature worms are in the intestinal canal. Then purgatives and 
athelminthics are indicated. In the very beginning of the attack, 
emetics may do good. Afterwards, in spite of the diarrhea, purgatives 
should be freely given. Calomel in rather large doses should be given 
every three or four days, followed by full doses of castor-oil. Injec- 
tions of corrosive sublimate, one to two thousand, may also be given. 
Benzine, given both by the mouth and as a rectal injection, has been 
recommended. After the worms have left the intestines, no medication 
directed to their destruction is of any avail, and the general condi- 
tion alone can be treated. The prevention of the disease is as easy 
as its cure is difficult. Thorough cooking of meat, by which all parts 
of it are raised to the boiling point, is all that is required. Other 
modes of preparation of the meat, such as prolonged smoking, pickling, 
etc., have no effect on the parasite. (W. T. Councilman, M. D.) 



43 



CHAPTEE LV. 

MATEKNITY. 

The female organs subservient to generation are, the ovaries, the 
principal function of which is the secretion of the ovule, or female 
germ ; the Fallopian tubes, designed to receive the ovule and conduct 
rt into the cavity of the uterus ; the uterus, a kind of receptacle whose 
office it is to contain the fecundated germ during its period of devel- 
opment, and to expel it immediately afterwards, and, finally, the vagina, 
a membranous canal extending from the neck of the uterus to the 
external genital parts. Most of these organs are situated within a 
large cavity, the walls of which are composed of bones and soft parts. 

On account of the importance of the pelvis as an organ both of 
protection and transmission, we shall begin the study of generation 
with it. The pelvis is a large, irregular, bony cavity, otr sort of a 
curved canal, which terminates the trunk inferiorly, and sustains it 
by its posterior part. It is placed directly upon the lower extremities, 
which afford it points of support, and to which, in the erect posture, 
it transmits the weight of the body. Its position in an adult of 
ordinary stature is, in general, about the central part of the whole 
trunk. The bones which together constitute the pelvis are the sacrum 
and the coccyx, both placed behind and on the median line, and the 
ossa-innominata bones. These last are in pairs, being situated at the 
sides and articulating with each other in front. The sacrum is a 
symmetrical, triangular bone, curved forward at its lower part, placed 
at the posterior part of the pelvis, where it appears like a wedge, 
forced in between the ossa-innominata, immediately below the verte- 
bral column and directly above the coccyx. It is transversed longi- 
tudinally by the sacral canal (a continuation of the vertebral canal) 
and relatively to the axis of the body ; it is directed from above down- 
wards and from before backwards; hence, the column represented by 
it forms an obtuse angle with the lumbar vertebrae, being salient in 
front and receding behind. This point is called the promontory, or 
the sacro-vertebral angle. Besides this direction the sacrum is curved 
upon itself from behind forwards, so as to present an anterior con- 
cavity, the hollow of the sacrum. 

The external organs of generation are the genital apparatus of 
the female, much more complicated than that of the male, and com- 
posed of organs situated in the interior of the pelvis and of parts 
attached to its exterior. The former are the ovaries, Fallopian tubes, 
(674) 



Maternity. 675 

uterus, and vagina ; the latter, the mons- Veneris, vulva, and perineum. 
(See figure '2, page 98.) 

The mans- Veneris is a rounded eminence, a species of relief, 
situated in front of the pubis and surmounting the vulva. This emi- 
nence is partly produced by the bones and partly by the subcutaneous 
adipose tissue. The skin covering is very thick and elastic, but being 
little extensible, it can not aid in the enlargement of the vulva at 
the period of delivery. In the adult female, it is covered with hair 
and contains a great number of sebaceous follicles. 

The vulva is a longitudinal opening, or fissure, situated at the 
median line at the base of the trunk, bounded in front by the mons- 
Veneris, behind by the perineum, and latterly by the external labia. 

The labia majora are two cutaneous folds flattened transversely, 
which bound the opening of the vulva externally. The labia externa 
presents an external or cutaneous surface, which, after puberty, is 
covered with hair, and an internal one, moist, smooth, and of a rose 
color, which is formed by a mucous membrane having a quantity of 
sebaceous glands and papillae. There is an internal labia, contracted 
behind, continuous with the internal face of the external labia. 

The clitoris is a small, erectile, sensitive tubercle, resembling the 
corpus cavernosum of the male. Its free extremity appears at the 
front part of the vulva, about half an inch behind the anterior com- 
missure of the labia externa, and its body is attached by two crura to 
ischio-pubic rami. 

The urethra is situated just below the vestibule, about an inch 
from the clitoris, and immediately above the prominent enlargement 
of the anterior part of the vagina. 

The hymen is the irregular opening of the vagina, and is found 
beneath the meatus-urinarius. This membrane is regarded as the seal 
of virginity. 

The internal organs of generation are the vagina and the uterus, 
together with their appendages, the Fallopian tubes and ovaries. 

The vagina (or vulvo-uterine canal) is a cylindrical, membranous 
tube, extending from the vulva to the uterus. It is situated in the 
pelvic excavation between the bladder and the rectum, extending from 
the vulva to the superior strait. It has the same direction as the 
general axis of the pelvis, that is, it forms a curve, the concavity 
of which is anterior. Its length varies from four and a quarter inches 
to five and a quarter. The length of the vagina varies in different 
women. 

The uterus is the organ of gestation, in which the ovum is destined 
to remain from the period of escape from the Fallopian tube until 
the moment of final delivery. It is pear-shaped, flattened from before 
backwards, having its base turned upward, and the apex downward. 
It is divided into two parts, the body and neck. The body is the 
largest, and comprises more than half the total length ; the neck is 



676 Maternity. 

smaller, a slight circular constriction serving to indicate externally 
the union of the body with the neck. The uterus is from two and a 
half to three inches in length. The weight at puberty is from six 
to ten drams ; but in women who have borne children, it ranges from 
an ounce and a half to two ounces. 

The ligaments of the uterus are the anterior and the posterior, 
the broad and the round, which serve to retain the organ in position 
and to prevent its displacement. 

The Fallopian tubes are two canals, varying from four and a 
quarter to five inches in length, and placed in the thick, superior 
part of the broad ligament. They extend transversely from the lateral 
angles of the womb nearly to the iliac fossa on the corresponding 
side. Near the free extremity they spread out and become fringed, 
presenting what is called fimbriated extremity. 

The Fallopian tubes serve the double purpose of a canal for trans- 
mitting the fecundating principle of the male, and for carrying the 
germ furnished by the female from the ovary to the uterus. At each 
menstrual period the ovule passes with the serum current along the 
ovarian fimbria into the Fallopian tubes. 

The ovaries are analogous in the female to the testicles of the 
male; that is, both of them secrete a product indispensable to repro- 
duction. Two in number, they are situated on the sides of the uterus 
in that portion of the broad ligament called the posterior wing, just 
behind the Fallopian tubes. They are maintained in position by 
those ligaments, and by a special one denominated the ligament of 
the ovary. They are situated just on the inside of the crest of the 
ilium, a little to the back of the uterus, and are about the size of a 
pecan nut. 

Menstruation is a periodical flow of blood from the genital parts, 
having its source in the walls of the uterus. Its first appearance 
(which is always determined by the ovarian evolution, of which it is 
one of the ephiphenomena) reveals the aptitude of the female for 
fecundation, and constitutes one of the earliest signs of puberty or 
nubility. These phenomena are both local and general. The first, 
which is purely physical, occurs more especially in the generative 
organs. The pelvis increases in size in every direction, and gradually 
assumes the shape indicated as peculiar to the well-formed woman; 
the breasts rapidly develop, and the nipples become more projecting, 
turgescent, and sensitive ; the skin surrounding the latter also becomes 
darker in color than before. The outlines of the body at the same 
time become rounded, in consequence of the greater abundance and 
more harmonious distribution of the cellulo-fatty tissue. The voice 
assumes a softer tone. Timidity and often embarrassment are shown 
in the presence of people with whom, but a few months previously, 
the young girl sported as a child. The congestion which precedes 
the flow is indicated by new symptoms. The young girl complains 



% Maternity. 677 

of lassitude, of a sensation of swelling and weight in the loins, of 
heat in the hypogastrium and peritoneum, of a slight itching and 
tumefaction in the genital parts, and a painful swelling of the breast. 
Strange disturbances not infreqeuntly occur, and I have sometimes 
observed attacks of genuine hysteria. Quite frequently the first men- 
struation takes place without having been preceded by any of these 
discomforts. 

Pregnancy is effected in the human species through the medium 
of two sexes, distinguished by the possession of different organs. The 
sexual character, therefore, being peculiar to distinct individuals, these 
evidently must first approach each other before generation can take 
place. This first act constitutes copulation. The consequence of the 
approach is an application of the fecundating principle of the male 
to the germ furnished by the female ; in other words, conception or 
fecundation. The ovum, after it has been fecundated, remains, and 
is developed in the organs of the mother during the whole term of 
gestation. Lastly, at the expiration of a nearly uniform period, the 
new being is expelled, to maintain thenceforth a separate existence. 
This final act is called labor. Pregnancy is, therefore, the condi- 
tion of a woman who has conceived and bears within her womb the 
product of conception. This state commences at the instant of fecunda- 
tion and terminates with the expulsion of the body which results 
from that function. It continues for two hundred and seventy davs, 
or nine lunar months. 

HYGIENE AND MANAGEMENT OF PREGNANCY. 

Hygiene of Pregnancy. — To be carried safely through the period 
of utero-gestation, the most critical time of her life, physiologically 
speaking, the pregnant woman needs special care. Particular atten- 
tion is to be given her in the selection of diet, and in exercise, rest, 
sleep, clothing, and bathing. Her mental condition is to be watched; 
her attention diverted. The condition of the breasts calls for some 
prophylactic treatment. 

Diet. — Very early in pregnancy the desire for food is dimin- 
ished, and certain unusual articles of food may be craved. Fair 
quantities of food are at times partaken of, and its kind and vari- 
ety are always to be considered. The morning sickness is thus 
sometimes best abated. In the fourth month gastric irritibility 
usually subsides spontaneously, the appetite reappears, and the diges- 
tion improves. All foods, animal and vegetable, that are reasonably 
digestible and nutritious, are best suited to her condition. In a word, 
the diet of a pregnant woman should be plain, simple, easy of diges- 
tion, highly nutritious, and partaken of at regular intervals. A good, 
general supply of nitrogenous food, with vegetables and fruits, is. 
called for. As some foods do not agree equally well with all patients,, 
personal likes and idiosyncrasies must be consulted. A generous diet 



678 Maternity. 

improves hematosis, increases functional activity, augments body weight 
and heat, imparts tone and firmness to the blood-vessels and tissues, and 
diminishes the susceptibility of the nervous system to pain and reflex 
irritation. That the diet must directly influence the growth, and devel- 
opment of the foetus in the womb is reasonably clear. In the latter 
part of pregnancy the gravid uterus rises to and presses upon the 
stomach; hence, food has to be taken in greater moderation, and at 
shorter intervals. A milk diet is at times especially needed. Albu- 
minuria is a condition calling for the use of milk, as recommended by 
Gamier. Its absolute use, strictly enforced, gives very good results in 
this complication. 

Exercise. — Moderate exercise can almost always be well borne. 
Violent exercise and excessive fatigue are invariably to be avoided. 
Extraordinary exercise, such as riding on horseback or over rough 
roads, dancing, or lifting heavy weights, is injurious. Long journeys 
by water or by land should be postponed if possible. 

Is parturition made more easy by unusual physical exercise ? 
Affirmatory opinions have been entertained. Doubtless women whose 
habits have accustomed them to considerable physical exercise can, all 
things being equal, undergo parturition easily and quickly; but those 
unaccustomed to any special physical exercise should undertake only 
what can comfortably be borne. If active exercise is not well borne, 
then passive exercise may be highly beneficial. Riding in the open 
air gives the pregnant woman the necessary fresh air and sunlight. 
Crowded and ill-ventilated rooms are to be avoided. While moderate 
exercise is needed in many or most cases, its continuance is objection- 
able in cases where the normal relaxation of the pelvic joints becomes 
excessive. The pubic joints, most often affected, are so relaxed at 
times that locomotion is impeded and rest demanded. 

Rest. — A pregnant woman needs an abundance of sleep, because 
of its health-giving, restoring influence. A portion of each day, after 
the midday meal, may well be selected for the assumption of the recum- 
bent posture, to obtain for an hour or two either rest or sleep. 

Clothing. — Great care is to be taken that the clothing is so 
adjusted as not to compress the abdomen and the chest. While the 
quantity and quality of the clothing are to be determined by the season 
of the year, the garments to be placed around the waist should be as 
light as is practicable and consistent with comfort. The clothing isr 
best suspended from the shoulders. The corset and tight-fitting skirts 
are injurious, impeding, as they do, the expansion of the growing 
uterus and its contents, and favoring the development of symptoms of 
a not uncommon complication of pregnancy, albuminuria with uraemia. 
Multiparas with relaxed abdominal walls often experience comfort 
from support to these parts by an abdominal bandage, thereby main- 
taining the uterus in a more normal position, wherein there is better 



Maternity. 679 

accommodation for the foetus. All possible pressure of the pelvic and 
renal veins is to be avoided. 

Bathing. — Baths are to be administered to the body at the usual 
intervals observed in health, daily in warm weather, and at least twice 
a week in cold weather. They are to be general, with an abundance 
of water and soap. The temperature of the bath may be either warm 
or cool, according to previous habits and to the season of the year. In 
the country where there are no conveniences for a body bath, a tepid 
sitz-bath, taken before retiring, is most beneficial. The body may be 
bathed with bicarbonate of soda, rubbing it on after wetting the skin, 
and letting it remain on a few moments before bathing. The temper- 
ature of the room should be about 80° Fahrenheit; bathe for about ten 
minutes, rubbing the body thoroughly all the while. The feet may be 
placed in a basin of tepid water while the body is being bathed ; it is 
especially necessary to keep up the functional activity of the skin, 
which is often quite impeded in the last weeks of pregnancy. 

Vaginal injections are required if there is leucorrhcea, vaginal or 
uterine. If an injection is required, there is nothing better than a 
saturated solution (one quart) of boric acid given with a fountain 
syrine in a very gentle current. 

There should not be much sexual intercourse. It often becomes a 
source of much pelvic discomfort to a great many, and it often may 
create an abortion. Even uncivilized nations have condemned the 
privilege of sexual intercourse during the period of pregnancy, and it 
is said that punishment is meted out to the offenders. It is better 
for the husband and wife to occupy separate beds during the months 
of pregnancy. 

Local Treatment. — Local treatment to the diseased cervix is often 
necessary during pregnancy. In the country it is almost impossible 
to have local applications applied, but it is different with our city 
women. Pregnancy aggravates cervical catarrh, from which come 
vaginitis and vulvar pruritis. The, gentle use of warm vaginal injec- 
tions is beneficial. Put a heaping teaspoonful of boric acid into a pint 
of boiling water ; let it dissolve, and when cool inject slowly about a 
half pint while in a recumbent position ; after waiting a half hour intro- 
duce into the vagina a piece of absorbent cotton dipped in sterilized lin- 
seed oil with a little turpentine added to it. (Turpentine one and a half 
drams ; linseed oil six ounces. ) Push the tampon well up against the 
uterus, having a string attached to the cotton, so that it can easily be 
removed. This treatment once or twice a day will give quick relief. 
Of course, when a pregnant woman can go to a doctor's office and have 
topical applications of astringents and emollients, and nitrate of silver 
in solution, aplied according to the judgment of the physician, it is 
much to be preferred, as this often arrests reflex disorders, such as 
nausea and vomiting. 



680 Maternity. 

Mental Hygiene. — The mental condition in pregnancy is always 
an important consideration. Emotional susceptibility is usually some- 
what increased. The pregnant woman, quite excitable and irritable, 
readily responds to external influences by which, in the non-pregnant 
condition, she would not be influenced. Sometimes she feels unusually 
well, is intellectually brightened and more active, takes greater care 
and interest in her household affairs, and says she is positively happier. 
At other times a certain despondency creeps over her mental state ; she 
is unusually morose; there is noticed irritable moodishness or peevish- 
ness beyond the control of the will; the sense of sight, hearing, smell, 
and taste, and the sensory or motor nerves are frequently perverted 
without any structural changes in the nerves concerned. It is thought 
that all these perversions or exaltations of function are directly or 
indirectly attributable to the quantitative and qualitative changes of 
the blood from pregnancy, and to physical changes going on in the 
sexual organs, creating reflex disorders. Structural alterations in the 
growing foetus may be effected, modified, or perverted by psychical 
influences; and certain fcetal disorders may result from maternal 
impressions. (See article on Maternal Impressions.) 

Physiologists admit, and observations prove, that the maternal 
emotions do affect the development of the exterior of the foetus, and 
may likewise alter the mental development in its complex and delicate 
organization. Idiocy may so result. The mind influences and modi- 
fies the body in ways unexplained. 

In view of these facts, the physician should aim to direct the men- 
tal condition of his patient; all sudden, unpleasant news, frights, and 
physical shocks are to be carefully avoided, and circumstances which 
improperly harass the pregnant woman are to be altered. Kind assur- 
ances are ever helpful. A judicious amount of amusement is not to be 
forgotten ; the mind is to be kept pleasantly occupied, and diverted into 
new, pleasing, and surprising channels, into agreeable and cheerful 
associations. Around the patient should be thrown a gentle, protective 
care, and she should be shown every care and be treated with con- 
siderate kindness. It becomes the duty of the husband to give his 
wife an intelligent cooperation, and thus help her to bear her burden. 

Management of Pregnancy. — It is the duty of every practitioner 
of medicine who is engaged to attend a woman in an expected parturi- 
tion to give her some general hygienic directions as to diet, dress, exer- 
cise, and the regulation of her bowels and skin ; the physician should 
also in a general way assume some professional care of her throughout 
her pregnancy. Many disorders and complications are liable to arise 
during this period, and much depends upon prompt and well-directed 
advice in their judicious management. 

There are many women in the country who never consult a physi- 
cian during their term of gestation until the time expires for the 
termination of pregnancy, nor even then in some cases, but they are 



Maternity. 681 

confined by a midwife. This article will be of use and benefit to such 
cases. A physician is not summoned or consulted, perhaps because 
there is none within reach, or it may be from lack of means, or from 
a motive of economy, or from ignorance, the woman thinking it is of 
no use, as they have heard of their mothers or grandmothers raising 
large families of children without calling in a physician on such occa- 
sions. Let me warn you, my countrywomen, that you are in this mat- 
ter risking your life. 

First of all, the stomach disorders most frequently occurring call 
for some attention. We have referred to dietetic management, which 
is more efficacious, it may be, than the medicinal treatment. 

Koumiss is recommended as being good when other foods can not 
be retained on the stomach. It may be necessary to administer food 
by the rectum. For the physiological nausea and vomiting of preg- 
nancy, the writer has found tincture of mix vomica, from one to three 
drops before meals in a little water, or oxalate of cerium from 
five to eight grains to be taken after meals in a little water, bene- 
ficial. Sodium bromide and cocaine are recommended by various 
writers. Electricity, the faradic current (secondary) over the stom- 
ach, applied for ten minutes (J. C. Cameron, M. D.), is also efficacious. 
The writer has had good results from the use of galvanism; put the 
positive pole over the stomach, and the negative pole in the right hand 
for ten minutes ; move the positive pole over the dorsal spine, and the 
negative in the left hand for ten minutes ; give from thirty to fifty 
milliamperes. This should be given daily if needed. 

Next, the alvine evacuations are to be maintained daily. A good 
diet and regularity of habits show good results. Magnesia, the min- 
eral waters, such as Congress, Hathorn, the sulpho-saline waters, or 
a solution of phosphate of sodium, or Carlsbad salts, or Seidlitz pow- 
ders, are indicated. Purgation is seldom needed. The best laxative 
remedies are aloin, podophyllin, cascara sagrada, and compound lic- 
orice powder. Above all, it is important that careful attention be paid 
to the kidneys. "To be forewarned is to be forearmed" is well illus- 
trated here. Albuminuria is said to be present in at least from five 
to ten per cent of the cases of pregnant women. Hence, the physi- 
cian should make a chemical analysis and microscopical examination 
of the urine to detect any possible alterations in its quantity and 
quality. 

A careful examination of the abdomen may be properly made 
after foetal viability; this should be done by the family physician. 
The mammary glands need ample room for their development to pre- 
pare them for the coming function of lactation. The nipples, espe- 
cially if retracted, should always be drawn out by the application of 
the index finger and thumb for a few minutes each day during the last 
six weeks of pregnancy. 



682 Maternity. 

Exposure of the breasts and nipples to the air doubtless tends to 
diminish their tendency to become sore and fissured. Daily ablutions' 
with cold water are always essential. A topical application of the fol- 
lowing as a prophylactic remedy for sore and fissured nipples is recom- 
mended, when it is thought desirable to use an astringent applica- 
tion : — 

Iji: Tannin 3j 

Glycerinse 3ss 

Aquse rosse 3ss 

Mix. 
Sig. : Apply daily as directed, several times. 

There are no two pregnant women alike, and no absolute rule can 
be framed for all. The expectant treatment is generally called for. 
Common sense has to be the guide of many women who are unable 
to avail themselves of the care of a physician. Only general prin- 
ciples can be laid down for guidance. A very frequent danger is that 
an abortion, or a premature delivery, may be caused by uterine con 
traction; any constitutional disease, especially syphilis, may require 
special medication. There are remedies which often favor uterine 
tonicity and become prophylactics against abortion. Viburnum pruni- 
folium, aletris, and cimicifuga doubtless favor the normal completion 
of gestation. 

In all cases as little medicine as possible ought to be given. Preg- 
nancy is best managed by an observance of the hygienic instructions. 

THE LYINGKEN ROOM. 

In private practise the patient is generally confined in the room 
which she is to occupy during convalescence. The choice of room is 
important. One of the first requisites of health at all times is pure 
air, and this should not be denied the patient. The need of oxygen is 
greater than usual, owing to the severe muscular activity of labor. 
When possible, therefore, a commodious room, one which permits of con- 
stant ventilation, should be selected. In cold weather an open fire is 
an efficient aid to ventilation, and adds greatly to the cheerfulness of 
the lying-in chamber. 

A sunny exposure is the most desirable. Dusty hangings should 
be removed; cleanliness is very necessary. 

On no condition should confinement be conducted in an apartment 
recently occupied by a patient with erysipelas, child-bed fever, sup- 
purating wounds, or other diseases which are recognized sources of 
possible sepsis, except after systematic cleansing and disinfection. 

The Nurse's Preparations. — An orderly nurse will have ready, 
conveniently near the bed, a small table covered with one or two 
freshly-laundered towels, and be supplied with a wash basin, a hand 
brush, soap and hot water, an antiseptic solution, scissors, a ligature for 
the navel, and a suitable aseptic lubricant for the hands. The nurse 



Maternity. 683 

should also see that there are plenty of clean sheets and towels, one or 
two pieces of unbleached muslin for abdominal binders a half yard in 
width by one and a quarter yards in length, one or two surgically clean 
rubber sheets (or oilcloth, if in the country where rubber sheets are not 
obtainable) large enough to cover the entire width of the bed, plenty 
of muslin sheets, a rug or oilcloth to protect the carpet beside the bed^ 
safety-pins of convenient size for pinning the binder, a fountain 
syringe, a suitable bedpan, a supply of hot and cold water, a package 
of salicylated or borated cotton for the navel dressing, a blanket for 
wrapping the child, and the child's clothing. 

Preparation of the Bed. — The patient should lie upon a firm mat- 
tress. It is customary to protect the bed by means of a rubber sheet, 
which ought to be large enough to cover the entire width of the bed 
and the greater part of its length. Over this rubber covering is spread 
a muslin sheet, the two coverings being pinned fast to the mattress. 
These spreads are covered with a second rubber overlaid with a bed 
sheet, and two or three freshly-laundered sheets, each folded to four 
thicknesses, may be placed upon the bed in position to receive the 
discharge. The latter coverings are withdrawn after labor, leaving 
the bed clean and protected by the first rubber and its muslin covering. 
In place of the sheets for absorbent dressing, an old clean-washed bed- 
quilt answers every purpose; also, oilcloth will take the place of rub- 
ber when rubber sheets are unobtainable. The entire bed must be clean 
in the surgical sense. All rags that are used in the lying-in room should 
be boiled thoroughly before using them about the patient. 

The Patient. — The patient should take a bath at the beginning 
of labor, an enema of warm water with castile soap, also a vaginal 
douche of a saturated solution of boric acid, one heaping teaspoonful 
to a quart of boiling water, cooled properly before using, and make 
an entire change of linen. She will usually prefer to be dressed in 
her night-clothing, over which, during the first stage, she may wear 
a loose wrapper. A napkin or a pad kept wet with Thiersch's solu- 
tion, and worn over the vulva during this stage, is a simple and useful 
antiseptic measure. 

The Obstetric Bag. — The obstetric bag should be large enough 
to contain all the instruments and other surgical appliances that may 
be needed in ordinary labor. The equipment should comprise obstetric 
forceps ; a Davidson syringe ; a glass uterine douche tube ; a soft rubber 
catheter ; a soft rubber tube, with bulb attached, for aspirating mucus 
from the child's throat in case of asphyxia ; a half dozen needles, about 
two inches in length, and straight or slightly curved, for suturing the 
perineum ; a few short curved needles, an inch and a quarter in length, 
for use in the vagina ; a needle forceps ; a knife for episiotomy ; steril 
ized sutures of catgut, silkworm gut, and of silk; one or two hand 
brushes ; a yard or two of plain aseptic gauze, for possible use in post- 
partum hemorrhage ; a Sims speculum ; one or two sponge-holding for- 
ceps ; a Volsella ; and a curette, and a catheter. 



684 Maternity, 

Physicians should also be provided with two or three ounces of 
chloroform, twice as much of ether, a few ounces of carbolic acid, a 
dram or two of chloral ; mercurial antiseptics, and obstetric emergents, 
such as morphine, elaterin, digitalis, ergot, and veratrum viride, are 
most conveniently carried in tablet form. 

ANAESTHESIA. 

By "obstetric" anaesthesia is understood something entirely dis- 
tinct and apart from the surgical use of anaesthetics. It is intended 
to diminish, not to abolish, pain. Its object is merely to mitigate the 
severer sufferings of ordinary labor, not to cause complete insensibility. 
With reference to the influence of anaesthetics upon the strength and 
the frequency of the uterine contractions, we have some recent observa- 
tions from Donhoff. 1 He administered chloroform, in various degrees, 
to five parturients, studying the effect upon the pains with the aid of 
a tokodynamometer. Even under small doses the labor was retarded. 
In eight observations the muscular pressure sank nearly to one-half 
that present before the administration, and the strength of the uterine 
contractions was not fully restored for several minutes after the inhala- 
tions were stopped. 

That the use of anaesthetics during labor predisposes, in some 
degree, to relaxation of the uterus in the third stage, as claimed by 
Lusk and others, is abundantly exemplified by the experience of J. C. 
Cameron, M. D., who states that the foregoing facts, while they do 
not forbid the employment of obstetric anaesthesia, call for the exer- 
cise of caution in its use. When required for no other purpose than 
to mitigate the sufferings of the patient, anaesthetics should be reserved 
until the latter part of the second stage, and even then they may be 
withheld so long as the pains are well borne. Their employment is 
permissible at an earlier period in the labor when required to subdue 
great nervousness and excitement or to relieve pains of extreme and 
unusual severity. 

"In the third stage of labor the use of anaesthesia is chiefly surgical. 
The relative safety of obstetric anaesthesia lies not in any peculiarity of 
the subject, but in the mode of administration, the limited dosage, the 
slow and gradual inhalation, and the intermittent use of the drug, dur- 
ing the pains only. Under complete anaesthesia the parturient woman 
is exposed to the same dangers as are other patients. 

"In cases in which an operation must be performed requiring 
anaesthetics, neither disease of the heart, of the lungs, nor of the kid- 
neys, nor the exhaustion of the third stage of labor, forbids their use. 
These conditions, however, necessitate increased caution in the admin- 
istration. In cardiac disease, even in lesions of the myocardium, 
anaesthetics lessen the danger by subduing the reflexes." (I. C. Cam- 
eron, M. D.) 

^rcbiv. fur Gyon, Band 42, 12. 



Maternity. 685 

Choice of Anaesthetics. — For mere obstetric analgesia, chloroform 
is generally preferred. It has the advantage of being pleasanter than 
ether, and less bulky to carry. Ether, however, seems to be growing 
in favor for obstetric use, and it is claimed to be no less manageable 
than chloroform for partial anaesthesia. Hirst thinks ''analgesia is 
even more promptly produced by ether than by chloroform. The satis- 
factory use of ether for this purpose depends upon its proper admin- 
istration. It must be given very gradually, in quantities of a few 
drops with each inspiration. The difference in the two agents is 
insignificant when used in the obstetric method." 

J. C. Cameron, M. D., of Montreal, Canada, advises: "When 
insensibility is required for surgical interference, chloroform should, 
as a rule, give place to ether. The general mortality from the use 
of chloroform when pushed to the surgical degree is four or five times 
greater than that of ether. Of the two agents, chloroform is the more 
potent, and its effects persist longer after inhalation stops. Ether, 
since it is used in larger quantities, is more irritant to the air passages 
than is chloroform; hence, ether should be replaced by chloroform in 
inflammation of the air passages, especially if it be acute. The patient 
is prepared for anaesthesia by loosening the clothing, by lowering the 
head, and such other precautions as are commonly observed in phys- 
ical practise. To protect the skin from irritating effects of the chlo- 
roform vapor, the lips, nose, and chin should be smeared with vaseline 
or with glycerine. A towel spread in one thickness over the head, 
and lifted at the middle so as to form a large cone-shaped air-chamber 
about the face, makes a suitable inhaler. A folded handkerchief may 
be laid over the eyes for protection from being burned. 

"On the first premonition of a coming pain, the inhaler is placed 
over the face of the patient, and the anaesthetic is dropped upon it oppo- 
site the mouth. With chloroform, one drop, or at the most two drops, 
should be allowed to fall at each breath. In case ether is used, three 
or four drops with each inspiration" will suffice. When sufficient effect 
is not obtained in this manner, the patient may be required to breathe 
rapidly as the pain is coming on. 

"For convenience in graduating the administration, a bottle spe- 
cially constructed for the purpose may be used, or a dropping bottle 
may be improvised by cutting a longitudinal slit in the side of the 
stopper. 

"The foregoing methods of administration insure an abundant 
dilution of the anaesthetic vapor with air, and a safe and gradual 
development of anaesthesia with the least possible quantity of the drug. 
The inhaler should be removed on the approach of unconsciousness, 
and should always be withheld in the intervals between the pains. 
During the severer pains at the acme of expulsion, the inhalation may 
usually be pushed nearly or quite to the surgical degree." 



686 Maternity. 

Other Anaesthetic Agents. — An agent of great value as a partial 
substitute for the anaesthetic vapors is chloral. It is particularly use- 
ful for alleviating the pains of the first stage when they are not well 
borne. From forty-five to sixty grains may be given in doses of from 
ten to fifteen grains, repeated every half hour. The total quantity 
should not exceed a dram (sixty grains). Under the full dose the 
patient usually bears the pains with but little complaint, and sleeps 
quietly in the intervals. Chloral, in the quantity mentioned, has no 
inhibitory effect upon the uterine contractions. In disease of the 
heart, either organic or functional, the wisdom of its employment is 
questionable, owing to its depressant effects. It is said by some author- 
ities to be unsafe to give chloroform to a patient who is already under 
the influence of chloral. From an eighth to a quarter grain of the 
sulphate of morphine, administered hypodermically, as a rule acts 
kindly in unusually painful labor, but it is rarely to be recommended 
in strictly normal conditions. 

Examination During Labor. — On reaching the patient, in response 
to her summons, the first duty of an obstetrician is to see if labor has 
actually begun. But first the hands must be made clean and antisep- 
tic ; good, old lye soap, such as will be found in the country, answers 
the purpose for cleansing the arms and hands. The beginning pains 
are not always to be taken as evidence that active labor is near at hand. 
Painful uterine contractions are sometimes experienced at intervals for 
days before the birth. Rarely after they are fully established they 
may wholly cease for an hour. 

Inquiry should be made for the usual phenomena of beginning of 
labor, the time when the pains began, their character, strength, and fre- 
quency. The first uterine contraction of childbirth frequently gives 
rise to little more than a sense of pressure in the sacral and lumbar re- 
gion. As the labor progresses, the effects are felt in front over the lower 
abdomen and finally down over the thighs. If the labor is in actual 
progress, a systemic external and internal examination is to be made. 
Examination of the abdomen will determine whether the child is liv- 
ing, what is the presentation and position, the quality and frequency 
of the foetal pulse, how far the head has descended in the pelvis, and 
the presence of anything that may complicate the birth. The relative 
size of the head and pelvis may be estimated by observing how far the 
head has sunk, or can be made to sink, into the excavation. The char- 
acter of the foetal heart-sounds affords important information as to the 
prognosis for the child, and they should be listened to frequently 
throughout labor. 

A foetal pulse rate much above or below the normal range, or a 
pulse which grows progressively weaker, indicates danger to the child. 

Before examining internally, the nurse should be directed to 
clean the abdomen, the vulva, and the inner surfaces of the thighs 
with soap and water, and finally with an antiseptic solution. From 



Maternity. 687 

this examination the obstetrician learns, first, the condition of the 
vulva and the degree of resistance it will be likely to offer as the head 
descends; second, whether the vagina is well lubricated by the secre- 
tions, and the presence or absence of obstructions ; third, the condition 
of the cervix, how far dilated, and whether dilatable as judged by the 
extent of softening and thinning ; fourth, the size and protrusion of the 
bag of water; fifth, the presentation and position of the child in con- 
firmation of the abdominal examination. 

Vertex presentations are recognized by the hardness and the 
globular shape of the cranial portion of the head and by tracing the 
sutures and fontanels. The examination must be made with care, 
using firm pressure, and searching as far as the fingers can reach, as 
the anatomical character of presenting parts is often somewhat obscured 
by the caput succedaneum. In other than vertex presentations, still 
greater pains will generally be needed to identify the presenting part. 
The position is determined by finding in which quadrant of the pelvis 
the small fontanels lie. This is best located by first tracing the sagittal 
suture. 

The examiner will learn whether the membranes are still intact, 
and how far they protrude during a pain, and will make sure that a 
loop of the cord has not prolapsed into the bag of water. In this part 
of the examination care will be needed, lest the membranes be pre- 
maturely ruptured. 

A question which is invariably asked is, "How long will the labor 
last V 9 A definite answer is seldom possible at the beginning of labor. 
The prognosis, so far as it can be estimated, must be based on the 
strength and frequency of the pains, the extent of dilatation and the 
dilatability of the cervix, the position, size, and hardness of the head, 
and the degree of descent. When nothing abnormal has been discov- 
ered, assurance should be given accordingly. 

Ma7iagement of the First Stage of Labor. — During the first stage 
of labor the patient ought not, as a rule, to be confined to the bed until 
dilatation is well advanced. She is usually more comfortable if allowed 
the liberty of the room, and the pains are thereby promoted. Much 
walking is not advisable, however, before the head has engaged ; it may 
cause prolapse of the cord or the small parts, and may hinder engage- 
ment. If the membranes rupture, or if the pain assumes unusual 
intensity, the patient must be kept in a reclining posture upon the bed 
or a lounge. Malpositions are often capable of correction by the 
woman's being required to lie upon the side toward which that part 
of the head points that is to lead the descent. 

For example, in a right occipito-posterior position, the patient 
should lie on the right side, and in a left posterior position of the 
occiput, upon the left side. The clothing should be loose, and limited 
to a wrapper and the underclothing. 



688 Maternity. 

During this stage, place hot antiseptic cloths, steamed or wrung 
out of boiling water, over the symphysis pubis down over the vulva, 
and a hot bottle of water against the compress, and change when needed. 
A little carbolic acid added to the water is advisable for asepsis. This 
affords comfort in the first stage of labor. If the obstetrician has, in 
the first examination, become satisfied of the absence of complications, 
the vaginal examination will rarely need to be repeated until the rup- 
ture of the membranes. When the protruding bag breaks before the 
head is engaged, it is well to make sure that a loop of the cord has not 
been swept down with the gush of water. 

The physician's first visit should be prolonged sufficiently to form 
some estimate of the probable rapidity of the labor and of the length 
of time before his attendance will be required. On departing, all 
needed instructions should be left with the nurse. The patient is to 
be allowed such food and drink as may be necessary, to be warned 
against voluntary expulsive efforts, and usually to remain off bed until 
the pains are severe The lower bowel should be cleared with an enema 
of warm soap-suds, and the bladder frequently evacuated. 

It is better for the obstetrician not to remain with the patient 
until the os has reached the size of a silver dollar, even after his or her 
continuous presence at the house is required, and not then in most 
cases, except when attentions are needed by the patient. I have heard 
women say the approach of a doctor would check their labor pains. 

Throughout the labor idle bystanders should, as a rule, be" 
excluded from the lying-in chamber. The presence of the husband is 
a matter to be left to himself and the patient. Both the mother's and 
the foetal pulse should occasionally be counted. 

All manifestations within the passages for the purpose of acceler- 
ating the labor in normal cases are to be scrupulously avoided. When 
the anterior lip of the cervix is caught over the occiput, and apparently 
retards the progress of the labor, it may be hooked forward during a 
pain until it retracts above the head. This is rarely necessary, and is 
very liable to abuse. 

Management of the Second Stage. — In the second stage of labor, 
as in the first, so long as all is normal, the duties of the obstetrician are 
few and simple. From the time dilatation is nearly complete, the 
patient must not, as a rule, be allowed to leave her bed. She may use 
a bed-pan for the evacuation of the bowels, and may have to use a 
catheter to void the bladder. The catheter must be aseptic, and the 
vulva washed with hot carbolized water before introducing it. She is 
to be dressed in the usual night-clothing, and the nurse may now turn 
up the hem of the gown, and pin it to the yoke with two safety-pins, and 
pin a folded sheet around the waist in front and over the thighs and 
knees for a covering. When the pains are feeble, their intensity may 
be increased by requiring the patient to move about in the bed, or even 
to assume for a time a sitting or half-sitting posture. The uterine 



Mateiifiity. 689 

expulsive efforts should be reinforced by the voluntary muscles. The 
patient may be directed to "hold the breath and bear down with the 
pains." 

Most women, during expulsive pains, instinctively brace their feet 
and catch the hands of the nearest bystander to assist the straining 
effort by pulling. Except in precipitate labor, this practise is to be 
encouraged. A sheet rolled into a loose rope and fastened by one end 
to the foot of the bed makes a convenient and efficient sling for the 
purpose. An abdominal binder is frequently useful in helping the 
progress of labor during the second stage, particularly in multipara 
having lax abdominal walls. 

The distressing sacral pains so common in the expulsive stage of 
labor may be relieved in some degree by pressure or rubbing hard over 
the painful region. For this purpose the nurse, taking position on the 
bed behind the patient as she lies upon the side, supports the back by 
pressing firmly against the sacrum with the palm of the hands during 
the pains. Cramps in the lower limbs are best overcome by powerfully 
contracting the antagonistic muscles. In case of cramps in the calf of 
the leg, for example, the patient should forcibly flex the foot and hold 
it so until the muscular spasm subsides. 

RUPTURE OF THE MEMBRANES. 

When the bag of membranes does not burst spontaneously by the 
time it reaches the pelvic floor, it should be ruptured by the obstetrician. 
Care must first be taken to see that a loop of the cord has not slipped 
down beside the head, as that condition of things would be seriously 
complicated by the escape of the water. It is not usually difficult to 
tear the sac with the finger-nail during a pain. Failing by this 
method, sharp-pointed scissors, previously sterilized, may be used. A 
convenient instrument is a sterilized coarse hairpin. It is first straight- 
ened, and then held over a flame. This perforator is passed on the 
finger-tip as a guard and guide, and. the bag of membrane is punctured 
while tense during a pain. 

Obstetric Position. — As a rule, the posture of the patient should 
be largely left to her own choice. Occasional changes relieve fatigue. 
In simple slow labor, the pains are hastened by permitting her to move 
about in bed, and now and then take a sitting posture ; until the head 
reaches the pelvic floor a half-sitting posture is most favorable, since 
the propelling force thus acts most effectively in the line of descent. 
At the perineal stage, the lateral position, with the body flexed, which 
position is most advantageous for the obstetrician, is at the same time 
advisable from the standpoint of mechanism. A blanket made into a 
roll and placed between the knees, or a pillow doubled, answers well for 
the comfort of the patient while in the lateral position. The lower end 
of the sacrum is tilted backwards, and some advantage, perhaps, may 
be derived from the fact that gravity acts more nearly in the axis of 



690 Maternity. 

expulson. All that the obstetrician needs to know in normal cases can 
usually be learned by abdominal palpation and auscultation. The 
descent of the head may be followed by palpating over the lower- 
abdomen until the occiput has reached the floor of the pelvis. From 
that time the progress of descent may be noted by the touch through 
the pelvic floor, and during the last moments of expulsion by ocular 
inspection. Frequent vaginal examinations expose the patient to pos- 
sible infection in spite of due care in the way of asepsis. A bowl of 
boiling water should be conveniently placed with carbolic acid or some 
kind of antiseptic added to the water, and each, time the obstetrician 
has to examine the patient during the process of labor, the hands 
should be washed. Have plenty of fresh-laundered towels at hand, 
which have been sterilized for the obstetrician's use. 

Prevention of Injuries to the Pelvic Floor. — In strictly normal 
conditions, muscular structures of the pelvic floor slowly relax under 
the pressure of the gradually-advancing head, and escape intact. The 
fourchette, however, is frequently torn in first births. In cases of 
relatively small vulvo-vaginal outlet, and in rigidity of the structures 
from whatever cause, the parts will generally be lacerated during the 
expulsion of the head in spite of the most skilful efforts on the part 
of the obstetrician. 

The order in which the tissues give way is fascia, muscle, mucous 
membrane, and skin. Accordingly, a laceration may occur subcu- 
taneously, the tear being confined to the muscle and fascia, and no 
breach of continuity appearing to the eye. As the cause of the tear 
is undue strain upon the resisting girdle through which the head passes 
at the moment of expulsion, it is plain that any measure, to be of value 
in preventing the injuries in question, must do one or both of two 
things: It must act to promote the relaxation and distensibility of the 
pelvic floor, or to lessen the tension to which it is subjected during the 
birth, or both. The former object is best accomplished by the slow 
and gradual delivery of the head, permitting time for the tissues to 
stretch ; the latter, by so regulating the head as to keep its smallest cir- 
cumference in the grasp of the resisting girdle and the propelling power 
directed in the axis of the outlet. The rate of descent is perfectly 
at command of the obstetrician. The expulsive force of the abdominal 
muscles may sometimes be suspended by requiring the patient to breathe 
rapidly during the pains. This, however, is not always possible. The 
action of the abdominal muscles is at this stage frequently involuntary, 
and wholly beyond the control of the patient. Most effectual for the 
regulation of the expelling powers is the use of anaesthetics. Chloro- 
form or ether should be given at this period on the appearance of the 
slightest danger of laceration. By the judicious use of the anaesthetics, 
the strength and frequency of the pains and the rapidity of expulsion 
may be regulated at will. The advance of the head, however, can still 
further be controlled by pressure with the thumb and finger held con- 



Maternity. 691 

stantly upon the occiput. With the thumb applied to the head immedi- 
ately in front of the tense border of the perineum, and with two 
fingers resting upon the occiput, the rate of descent is easily watched 
and regulated. 

To keep the tension of the vulva at a minimum, the long axis ol 
the cephalic cylinder must be kept at right angles with the plane of 
the outlet of the softer parte. Too rapid extension of the head must 
be prevented. The forehead should not be permitted to pass the per- 
ineum until the occiput is fully expelled and the nape of the neck rests 
in the subpubic arch. Moreover, to guard against too great strain 
upon the pelvic floor, the direction of expulsion must be regulated by 
crowding the head well up in the pubic arch, especially at the time 
when the equator of the head passes the vulvar ring. The expelling 
force is thus directed in the axis of the outlet, and the least possible- 
downward thrust is exerted upon the pelvic floor. 

The foregoing manipulations are best conducted with the patient 
in the left lateral position. In first labors, therefore, and in others 
in which the perineum is liable to be torn, the patient should, as a rule, 
be placed upon the left side, with the buttocks close to the edge of the 
bed, and a pillow doubled placed between the knees, as soon as the 
head has reached the floor of the pelvis. There is rarely danger of 
laceration until after the occipital pole appears in the vulvar fissure. 
Usually up to this point the progress of the perineal stage, when not 
over-rapid, may be noted by touch alone. With the finger upon the 
perineum just behind the posterior vulvar commissure, the occiput can 
be felt through the soft parts some time before it begins to distend the 
perineum, and the rate of descent can be observed as accurately as by 
passing the finger within the passages. 

From the moment the occiput appears in the vulvar orifice, the 
soft parts ought to be under ocular inspection. The vaginal discharges 
are occasionally washed away with a cloth which is kept lying in a 
warm antiseptic solution. The tension of the resisting ring may be 
tested by now and then passing the finger within the vaginal orifice 
during the pain. 

The head is allowed to advance until the perineal edge becomes 
as tense as is deemed safe. Its further progress is then arrested by 
direct pressure with the fingers in the line of descent. Until about to 
be expelled, it is driven down with the pains, and recedes in the inter- 
vals ; by this to-and-f ro movement the pelvic floor is moulded, as it 
were, to the required degree of distention. 

When the bregma appears at the edge of the perineum, the head 
no longer recedes between the pains, and is on the verge of expulsion. 
During the passage of the equator of the head, extension must be 
prevented by upward pressure in the axis of expulsion with the thumb 
placed upon the sinciput close to the perineum, the fingers resting upon 
the occiput. The sinciput must not be permitted to advance faster 



692 Maternity. , 

than the occiput If required for better control, both hands may be 
used. 

A favorite method for managing the expulsion of the head is the 
following: The patient lying upon the left side close to the edge of 
the bed, the operator, sitting behind her, grasps the head with the fin- 
gers of the right hand placed just in front of the fourchette, while the 
left hand, passed over the abdomen and between the thighs of the 
mother, seizes the occiput. This procedure gives easy command of the 
birth of the head, yet offers no important advantage over simpler 
methods. As a rule, in first labors, a half hour or more will be required 
from the time the pelvic floor begins to be distended until the head can 
safely be allowed to pass. In subsequent births a shorter time will 
usually suffice. 

There is no objection to the use of gentle pressure upon the head 
through the lateral aspects of the pelvic floor. For this purpose, the 
" hand may be laid flat upon the bulging soft parts, with the thumb 
extending along the right and the fingers parallel with the left labium. 
The hand should rest lightly upon the median-line thinned-out portion 
of the perineum, the pressure being applied mainly to each side of it. 
It must be borne in mind, however, that the object is to regulate the 
expulsion of the head rather than to support the perineum. Much 
compression of the tense pelvic floor, especially its thinned-out median 
portion, between the child's head and the obstetrician's hand, must tend 
rather to increase than diminish the danger of rupture. If the 
patient lies upon the back during the perineal stage, it will be found 
more convenient to regulate the expulsion by the thumb placed upon 
the occiput and the first two fingers upon the head in front of the 
frenulum. The introduction of the fingers into the rectum for the 
purpose of shelling out the head, even when practised between the 
pains, is more likely to cause than to prevent laceration by too pre- 
cipitate delivery." (J. C. Cameron, M. D.) 

Episiotomy. — It is said that no one method yields better results 
in preserving the integrity of the perineum than episiotomy, rightly 
timed and properly executed. The ultimate condition of the pelvic 
floor after episiotomy correctly performed, is even better than after 
many natural deliveries in which the parts escape rupture. It should 
be skilfully performed. The incision should be closed after labor, 
with a running or an interrupted suture with fine catgut. The wound 
may generally be closed without waiting for the delivery of the placenta, 
thus avoiding the necessity of renewing the anaesthesia. During the 
suturing, the patient may lie on the back, or on the side opposite the 
one being repaired. 

Management of the Cord. — The moment the head is born, a finger 
is slipped within the passages to ascertain if the cord is coiled about 
the child's neck. When so found, the loop or loops should be drawn 
down one by one over the head. Should the cord be so taut that it 



Maternity. 698 

can not be brought down, — an accident that must be extremely rare, — 
the cord may be tied at two points, and be cut between the two ligatures, 
and the trunk promptly delivered. 

Delivery of the Trunk. — The head should now be held in the hand 
to keep it in the axis of expulsion. While the anterior shoulder lies 
behind the symphysis, the finger is passed over the dorsal aspect of the 
posterior shoulder and is slipped into the axilla. Some operators 
deliver the anterior shoulder first according to the usual teachings. 
Having now passed the finger into the axilla, the posterior shoulder is 
then folded forward, and is cautiously lifted over the perineum. 

Except in emergency, calling for immediate delivery in the interest 
of mother or child, the expulsion of the trunk is left to nature. It is not 
a good practise to drag the child out of the uterus. The uterus should 
be compelled to expel it. The presence of the trunk and the extrem- 
ities stimulates contractions, and time is permitted for retraction. 
When necessary, the expulsion of the trunk may be hastened by the 
use of friction over the uterus. 

On the expulsion of the head, the face should be bathed, and the 
skin about the eyes should be carefully cleansed and thoroughly dried 
as a preventive against ophthalmia. Mucus in the pharynx should 
quickly be removed by the finger covered with a piece of soft wet muslin, 
or by the use of a soft rubber tube with an aspirating bulb attached; 

Ligation of the Cord. — The time for tying the cord is by no means 
a matter of indifference. Systematic observations have shown that a 
child gains from one to three ounces of blood by delaying the ligation of 
the cord for several minutes after birth; that in reported cases thus 
treated, the children are notably more robust than when immediate 
ligation has been practised, and that the usual loss of weight during 
the first few days of infancy is diminished. 

"This post-natal transfusion of blood is a fact of no little impor- 
tance, especially in prematurely-born and anaemic or puny children. 
According to Budin and Ridemont,' it is mainly the result of thoracic 
aspiration. Schucking, Porak, and Fritsch, however, attribute it 
chiefly to the pressure exerted upon the placenta by the uterine con- 
traction and retraction." 

Since the child's heart may be endangered by forcing too much 
blood into the circulation, compression of the uterus should not be 
practised before the cord is tied. 

In certain emergencies, ligation may be necessary, owing to the 
mother's requiring the obstetrician's entire attention. In cases of well- 
developed, vigorous infants, the rule of late ligation is not of so much 
importance. The usual practise now is to tie the cord after notable 
pulsation has ceased, and the respiration is fully established. 

In case of twins, the cord should always be ligated on the maternal 
as well as on the foetal side, owing to the possibility of a vascular connec- 
tion between the placentas. A suitable material for the ligature is a 



694 Maternity. 

narrow linen tape or surgeon's plaited silk ligature. The ligature 
should be dropped in an antiseptic ready for use. The common prac- 
tise is to tie from one and a half to three inches away from the 
umbilicus. The ligature should, therefore, generally be placed not 
more than an inch to a half inch from the cutaneous line. It is to be 
tied as tightly as it can be drawn, with care to put no strain on the 
umbilical insertion. Before tying, the cord, unless it is already thin, 
should be pinched firmly between the thumb and finger at the point 
to be ligated. This procedure is considered better than stripping the 
cord to thin it before ligating, which is more liable to do violence to the 
navel. 

The cord is divided within a quarter inch of the ligature. It is 
cut with clean antiseptic scissors while held in the hollow of the hand 
to guard against injuring the child. A bit of cheese-cloth or absorbent 
cotton pressed a few times against the cut end of the stump will show 
whether the vessels are securely tied. It is a common practise to place 
a second ligature a short distance from the first to control the maternal 
end of the cord. This promotes cleanliness, and, it is generally 
believed, favors the plancental expulsion. 

Management of the Third Stage. — Upon the skill and attention 
given to this period, the immediate safety of the mother and the rapid- 
ity and completeness of her recovery will often in great measure 
depend. The chief dangers of this stage are those which grow out of 
a relaxed condition of the uterus, — hemorrhage, embolism, and the 
retention of clots favoring sepsis and subinvolution. 

The management of the third stage is, therefore, mainly addressed 
to uterine contraction and retraction. 

From the moment the head is born, the uterus should be constantly 
watched, with the hand held flat upon the abdomen over the fundus, 
until evacuation is complete and the uterine globe as hard as a hand- 
ball. After the expulsion of the child, the patient is placed upon her 
back. The nurse, if she is competent, may be trusted to hold the 
fundus, at least while the physician is occupied with other duties. The 
hand is to be held quietly upon the abdomen so long as the uterus 
retains its normal consistence. Should the contractions be feeble, they 
may be stimulated by gentle friction. This friction is best practised 
by moving the lax abdominal walls over the uterus with a circular 
motion of the hand. More active interference is seldom required in 
normal cases. Marked flabbiness of the uterus and indistinctness of 
outline call for more energetic measures to produce contraction. 

When the placenta is not expelled after a reasonable time, resort 
should be had to the method of Crede, as follows: A half hour after 
the termination of the second stage of labor is allowed for the detach- 
ment of the afterbirth. If, at the expiration of that time, the placenta 
is still undelivered, friction is applied to the uterus until a vigorous 
contraction is induced. The hand is then placed in such posi- 



Maternity. 695 

tion upon the abdomen that the fundus rests in the hollow of 
the hand with the thumb in front and the four fingers behind. 

At the height of the contraction the uterus is compressed and thrust 
downward in the direction of the pelvic axis. If not at once suc- 
cessful, the process is repeated at short intervals until the object 
is gained. 

Until recently Crede advocated much earlier interference. 
Shortly before his death he recommended waiting thirty minutes. 
His procedure is now generally adopted. 

Traction upon the cord while the afterbirth lies in the upper 
uterine segment is considered inconsistent with the normal mechanism 
of placental expulsion. When the placenta has passed into the lower 
segment of the uterus or the vagina, no harm will be done by gently 
pulling the cord to assist the delivery. 

As the placenta is extended, the membranes are gradually detached 
from the uterus, care being taken that no fragments are torn off 
and left behind. To prevent this, the placenta is caught in the hand 
as soon as it passes the vulva; and if the membranes are not already 
free, they should be twisted into a rope by turning the placenta over, 
and the twisting continued until the separation is complete. 

Should a strip of membrane accidentally be left in the passages, 
it may be removed, if in the vagina or hanging from the cervix, by 
grasping it with the fingers and gently drawing it away, or by seiz- 
ing it with sterilized catch-forceps and twisting it off. Fragments 
of membrane remaining in the uterine cavity above the cervix are, 
as a rule, better left to be expelled with the lochial discharge, unless 
they give rise to hemorrhage. Placenta and membrane must be 
examined carefully to see if they are complete. To make sure that 
both amnion and chorion are entire, the membranes are best examined 
by transmitted light. 

The third stage of labor is not complete until uterine retraction 
is fully established. For at least half an hour after the placenta 
comes away, the uterus is to be watched with the hand upon the 
abdomen, using friction if necessary to provoke contraction. It is a 
useful precaution to give a half dram of the fluid of ergot at the 
close of labor, if the uterus is not firmly contracted. Its use is proper 
only after the evacuation of placenta, membranes, and clots. Its 
action is most prompt and certain when injected hvpodermically. One 
or two doses may be left with the patient, with instructions that they 
be taken in the event of flowing too freely. The use of a moderate 
dose of ergot at the close of labor is not only harmless, but is entirely 
in keeping with the object of treatment at this period. It limits 
the danger of hemorrhage, and by diminishing the blood supply, pro- 
motes involution. It closes the gates against infection, guards against 
the retention of blood clots in the uterine cavity, and therefore lessens 



696 Maternity. 

the tendency to after-pains and to putrid accumulations in the uterus. 

Cervical lacerations should be sutured at the close of labor in 
case they give rise to much hemorrhage. In the absence of trouble- 
some bleeding, the advantage of primary suture is thought to be 
doubtful. 

Lacerations of the pelvic floor, lacerated perineum, should be 
repaired as soon as the condition of the patient will admit. Lacera- 
tions of the pelvic floor should be immediately sutured. Perfect union 
may be obtained by operating at any time within twenty-four hours. 

Toilet of the Patient. — The child is received in two or three 
thicknesses of flannel previously warmed, is well wrapped, and laid 
in a warm place, the nurse then turning her attention to the mother. 
Soiled portions of her body are to be cleansed, best with an anti- 
septic solution; her linen, if necessary, is changed; all blood-stained 
articles removed from the bed. For bathing the genitals, a piece of 
freshly-boiled cheese-cloth is to be used instead of a sponge. 

Vulvar Dressing. — After cleansing, the vulva is covered with an 
aseptic dressing. A fresh-laundered napkin is suitable, or a lochia! 
guard of absorbent-cotton waste, or of cheese-cloth specially made for 
the purpose, may be employed. These dressings are best sterilized 
by steaming immediately before using. Flowing steam is most effect- 
ive. The object is to promote the cleanliness of the external parts, 
thus limiting the danger of infecting the passages from the decom- 
posing discharges. The use of some non-irritant antiseptic, like boric 
acid or bismuth powder, helps to retard putrefactive changes. One rub- 
ber sheet should be left in place under the sheet for four or five days. A 
draw-sheet placed under the hips of the patient is a convenient dress- 
ing for protecting the bed. A common muslin sheet folded four or 
five times answers for a draw-sheet, and should be replaced by a fresh 
one as often as soiled. 

Abdominal Binder. — This is useful to steady the uterus and pro- 
mote the comfort of the patient, especially when the abdominal walls 
are very lax. The usual material is a piece of domestic or unbleached 
muslin, one and one-half yards in length and about eighteen inches 
in width; this gives width enough to reach from the ensiform to a 
point below the trochanters. Unless the binder overreaches these 
bony prominences it is liable to slip up, and in a few hours is a 
mere rope around the body. Binders ready made with gores to 
fit the body offer no advantage. The pinning of the binder should 
begin at the lower border, and at the first application should be 
fairly tight. If the uterus shows a tendency to relax, three folded 
towels, used as compresses, may be placed on the abdomen under the 
bandage, one on either side of the uterus and one immediately above 
it. The binder may be dispensed with after one or two weeks. An 
antiseptic vaginal douche may be administered by the nurse the next 
day after labor, care being used in giving it ; in passing the vaginal 



Maternity. 697 

tube it should be kept close to the vaginal wall anteriorly all the 
while the douche is being given to prevent any of the water from pass- 
ing into the uterus; a teaspoonful of boric acid put into one quart 
of boiling water and allowed to cool to the proper temperature (100° 
Fahrenheit) may be administered daily. Every housekeeper should 
have a hospital bed-pan, a convenience seldom seen in this country. 

Asepsis. — Most important is rigid cleanliness of the external geni- 
tals of the patient, her linen, and bed-linen. The vulvar dressing 
should be changed every three to six hours during the first two or 
three days, and at all times as often as it becomes soiled. Each time 
the dressing is renewed, the external genitals and their immediate 
surroundings are to be carefully cleansed with soap and water, and 
finally washed with an antiseptic solution. A convenient method of 
cleansing the vulva is by irrigation with a fountain syringe, the stream 
being projected against the parts to be cleansed, and its action assisted 
by gentle friction with an aseptic cloth. A bed-pan in position beneath 
the buttocks receives the washings. If any fetor is perceptible, it 
must, as a rule, be assumed that the toilet of the patient has not been 
properly cared for. If the discharges become fetid, notwithstanding 
proper external precautions, an antiseptic vaginal douche should be 
given two or three times daily, or often enough to suppress all pubic 
odor. The douche tube, sterilized by boiling, is introduced for only 
one or two inches, w T ith care to avoid abrading the mucous surfaces. 
Carbolic acid, a teaspoonful to one quart of boiled water, or a 15-volume 
solution of hydrogen dioxide, in full strength or diluted with three 
or four volumes of water, may be employed. Linen should be changed 
as soon as soiled. 

After-pains. — These, if severe enough to deprive the patient of 
sleep, or to be exhausting, must be relieved.. A grain or two of opium 
or one-fourth of a grain of morphine may be given ; gum-camphor 
about the size of a small pea will usually relieve the pains, and may 
be given when necessary, though not oftener than every two or three 
hours ; one-half of a grain of codine is also valuable for this purpose. 
Some writers recommend chloral hydrate in doses of from twenty to 
thirty grains, well diluted in water or milk, as effective for relieving 
after-pains. The coal-tar analgetics are effective, but when repeated 
are open to objections, as they lessen the strength of the uterine con- 
tractions, and consequently retard involution. 

The lying-in woman perspires frequently and actively ; hence 
her skin ought to be bathed often with tepid water, or sponged with 
water and alcohol, equal parts. This bath should be followed by a 
gentle rubbing with a warm towel until the body is in a warm glow. 
Cleanliness of the bed is aided by the frequent changing of the draw- 
sheets, which are placed under the hips of the patient. 

Posture. — During the first few hours after labor, the patient 
should lie on the back; a small pillow may be placed under the 



698 Maternity. 

knees to afford comfort. After the uterus has become permanently 
retracted, and the vessels at the placental site are firmly closed by 
thrombi, the patient may lie on the right or left side. 

Best. — A sound sleep of several hours after delivery is a favorable 
prognostic. It not only speaks well for the condition of the patient, 
but is a potent restorer. Care should be taken, therefore, to procure 
rest and sleep as soon as possible after the necessary attentions to the 
mother and child have been completed. The room should be quiet, 
and the light subdued by drawing the curtains. It is especially 
important that the child does not disturb the mother's rest; it ought 
not to sleep in the same bed with the mother; and if it cries, it 
should be removed to another room. 

It is the duty of the physician to make a systematic examination 
of both mother and child at each visit. The principal points to be 
observed during the first days after delivery are the general appear- 
ance of the woman, whether she has rested sufficiently; what amount 
of nourishment she has taken, and what kind; the amount and char- 
acter of the flow; whether the bladder has been emptied, and the 
quantity of urine passed; if the bowels move daily after the first 
twenty-four hours ; the presence or absence of after-pains and their 
severity. The pulse and temperature are to be noted. The binder 
should be loosened at each visit, and the uterus examined through the 
suprapubic region to learn whether the bladder is disturbed. The 
urinary secretions as a rule are greatly increased during the first few 
hours after delivery, and injurious distention of the bladder frequently 
results. The condition of the breasts and nipples and the amount 
of milk secreted should be watched, especially during the first week. 
Daily inquiry should be made with reference to the child, whether 
it nurses properly and shows signs of thriving; the condition of the 
eyes, mouth, skin, the stump of the navel cord, and whether the 
bladder and bowels are properly evacuated. It is well for the first 
few days to know the rectal temperature, which the nurse should be 
instructed to take two or three times daily, and record on suitable 
blanks. This is important during the first week. After that time, 
if all is normal, a simpler record will suffice. 

Ventilation. — The atmosphere of the lying-in room must be as 
nearly pure as possible. Air should be admitted freely by open win- 
dows, as much as is consistent with a proper temperature of the apart- 
ment. As the air is constantly vitiated, so the ventilation, to be effect- 
ive, must be continuous. The sunlight may be admitted, but the eyes 
of the infant must be protected. 

Diet. — The diet for the first twenty-four hours is to be restricted, 
as a rule, to liquids. After the use of anesthetics no nourishment 
will be borne until the patient has recovered from their effect. The 
constant inhalation of good apple vinegar will very quickly relieve 
the sickness caused by the ansesthetic; it must be inhaled as long as 



Maternity. 699 

the breath gives off the odor of the anaesthetic. It may be administered 
by saturating a thick cloth with the vinegar and laying it on a piece 
of oilcloth, or rubber, or thick paper over the chest, or have the 
attendant hold it over her nose at first till relieved; then lay it on 
the chest, where it can be steadily inhaled. The writer knows by 
experience that apple vinegar, constantly inhaled, will relieve the 
nausea from an anaesthetic. As soon as nausea is relieved, a little 
nourishment may be given. AVarm liquid, such as clear soup, bouil- 
lon, gruel, cocoa, or a cup of hot tea, may be allowed directly after 
the close of labor, if no nausea is present. On the second day, soft- 
boiled eggs, boiled custard, panadas, and similar easily-digested foods 
are suitable. From this time on a moderately full diet is allowed. 
The dietary, however, must be varied to suit the individual case. As 
liberal a diet as the patient can digest is essential to the normal 
progress of the milk secretions. 

Retention of Urine; — The patient must be warned of the impor- 
tance of passing her urine within six or eight hours following the close 
of labor, and at similar intervals thereafter. The enfeebled control 
over the bladder in the first hours after delivery frequently leads to 
retention of urine. This is especially liable to occur from reflex 
disturbance, when the perineum has been sutured. Warm fomenta- 
tions over the meatus-urethra, the sound of running water, and moderate 
pressure applied with the hand over the pubic region, are useful aids 
in voiding the bladder. The catheter should be withheld, to be used 
as a last resort, owing to danger of setting up a more or less intense 
catarrh of the vesical neck from infectious material carried on the 
instrument. 

Use of the Catheter. — When catheterization is unavoidable, every 
precaution must be observed to prevent infection of the bladder. The 
soft rubber instrument is the easiest and most desirable for catheteriza- 
tion. Boiling the catheter a few minutes before using renders it 
antiseptic. Cleanse the genitals ,by washing with carbolized water, 
before using the catheter, which should be oiled with sterilized oil 
or vaseline. The labia should be held well apart, either by the patient 
or an assistant, so as to expose the meatus. The catheter should be 
warmed, and then passed in gently, only far enough to enter the 
bladder, until the urine begins to flow. Pinching the catheter firmly 
till it is withdrawn will prevent the urine from dripping when it 
is removed. The parts are cleansed with an antiseptic wash. If by 
accident the instrument becomes soiled through the process, it should 
be washed and then boiled in a little soda solution before being laid 
away. 

Evacuation of the Bowels. — The bowels should be evacuated not 
later than twenty-four or thirty-six hours after labor. A mild saline 
laxative, citrate of magnesium, or compound licorice, is also recom- 
mended. The action of the bowels may be assisted with warm water 



700 Maternity. 

and castile soap, or with a dessert-spoonful of glycerine in a pint of 
warm water. Epsom and Kochelle salts, equal parts, a tablespooiiful 
in a half glass of water before breakfast, is also a good laxative. 

Lactation. — The mother should, if possible, nurse her own child. 
In case of the mother's having consumption or syphilis, nursing the 
child by the mother is contra-indicated, owing to danger of infecting 
the child. 

The early application of the child to the breast promotes uterine 
contraction. As a rule, it is put to the breast after the mother has 
rested six or eight hours, sometimes earlier. It should be nursed 
once in four hours during the first few days until mammary func- 
tions are established. Usually the child will learn to nurse before 
the onset of the true milk secretion, and the painful engorge- 
ment of the breast will be diminished. Regularity in nursing is 
essential to both mother and child. The milk becomes concentrated 
by over-frequent suckling, thin and diluted when the intervals are 
too long. For this reason the child should not be permitted to sleep 
in the same bed with its mother, but should lie in a crib by itself. 
Bathe the nipples after each nursing with boric solution and care- 
fully dry and dust with bismuth powder. If the nipples are dis- 
posed to crack, burnt-alum powder is very effective for this purpose. 
Each time before nursing, the breasts must be washed. Cocoa butter 
is also very soothing to fissured nipples. During the first days of 
lactation the breasts frequently become fearfully swollen. Painful 
induration of the gland in the absence of inflammation is relieved 
by gentle massage, stroking the breasts outward from the base tdward 
the nipple. This is best practised immediately before putting the 
child to the breast. 

Distension from overfree secretion is relieved by saline cathartics, 
by abstention from too much liquids, and by the use of a compression 
breast bandage. This is made of a straight piece of muslin, with a 
shallow notch cut in one edge for the neck and a deep notch for each 
arm. The bandage is closely applied over the breasts, the ends being 
pinned in front. 

Not infrequently, especially in debilitated women, the supply of 
milk is insufficient. The most reliable evidence of defective lacta- 
tion is afforded by signs of inanition in the child. If the infant 
ceases to gain in weight, or if weekly gain falls short of the normal, 
in the absence of disease it is to be assumed that the quantity or qual- 
ity of the mother's milk is at fault. Attention to hygienic measures 
may improve the character of the mother's milk. Generous diet, 
including the use of milk, and attention to the hygienic surroundings 
of the mother, will improve the quantity; but caution must be taken 
not to eat more than can be digested. The daily application of a mild 
faradic current through the breasts, it is claimed, stimulates the mam- 
mary functions. Sulphate of strychnine, in doses of one-fortieth to 



Maternity. 701 

one-sixtieth of a grain, before meals daily, has a good effect as a gen- 
eral nerve tonic. 

In case of death of the child, where the milk must be dried up, 
an expectant treatment usually answers. A compress-binder may be 
used. Daily applications of oleate of atropia are of great value for 
the relief of pain and their specific effect in drying up the secretions. 
Restriction of liquids and the use of saline cathartics also help. The 
iodide of potassium, from ten to fifteen grains, doses repeated two 
or three times daily, exercises a remarkable influence in diminishing 
the flow of milk. 

Tardy Involution. — Nothing is better than the faradic current of 
electricity for hastening involution ; galvanism is also useful for this 
purpose. Friction applied two or three times daily is useful. This 
should be done gently, so as to give no pain, for about ten minutes each 
treatment. 

A mild faradic current of ten to fifteen minutes daily, or the gal- 
vanic current of twenty to thirty milliamperes, may be given the same 
length of time. The positive electrode is placed over the fundus of 
the uterus, or just above the pubis, and the negative electrode placed 
over the sacrum. A hot vaginal douche once or twice daily is of value 
for promoting involution. The temperature should be 115° Fahren- 
heit, and two gallons of hot water may be used. Ergot, in grain doses 
of the solid extract or its equivalent (fluid extract) may be given three 
times daily. Sometimes retarded involution is due to a septic condi 
tion of the endometrium. The remedy is a thorough curetting of the 
uterine cavity. An antiseptic gauze drain may be left in the uterus 
after curetting. The gauze should be removed on the second or third 
day, and sooner in case of fetid lochial discharges, and the uterus 
washed out with corrosive sublimate (1 to 5,000) ; the temperature of 
the water must not be over 110° Fahrenheit. 

Special Directions. — Considering the pressure effects of the term 
of gestation, and especially the latter part of pregnancy, the impaired 
nutrition, the loss of exercise and physical powers of many women, it 
is not surprising that childbirth is followed with more or less general 
debility, even in the absence of complications. Restorative measures, 
therefore, are necessary for convalescence. 

Plenty of sleep and proper diet have been alluded to. In addi- 
tion to these, tonics are of much service. In ansemia iron is called 
for. Gude's peptomangan is especially valuable. Park, Davis & Co.'s 
iron peptonate of manganese, administered in dessert-spoonful doses, 
three or four times a day in a wine-glass of water, are necessary to 
promote strength. The arsenate of iron is especially efficacious in the 
treatment of anaemia in puerperal women. Attention to the digestive 
organs is necessary, and the amount and character of the patient's food 
should be regulated. If the appetite is poor, a bitter tonic may be 
prescribed. 



i 



702 Maternity. [ 

(Elixir of calisaya with strychnine.) 

1$: Elixir calisaya %vi 

Nucis vomici 3jss 

Mix. 

Teaspoonful just before meals, in water, three times a day. 

A good general tonic is iron, quinine, and strychnia (J. Wyeth), 
elix. of iron quinine et strychnia, in teaspoonful doses after meals. 

Special attention should be given to the pelvic organs during the 
post-partum month. The first ten days after labor, a digital examina- 
tion should be made to ascertain the progress of involution; after that, 
the position and size can be determined by abdominal examination. 
After the third or fourth week the uterus should be examined with 
special reference to size, and shape, and position. If the uterus is 
retroverted, it should be reposited, and held in place by a suitable pes- 
sary for about three months. Often persistent retroversion may thus 
be prevented. 

If there is persistence of the red flow, or an abnormally open cer- 
vix, it is to be taken as evidence of endometritis. Iodized phenol, or 
Churchill's tincture of iodine, are recommended by some writers, to be 
applied to the endometrium at intervals of three days. Curettage, with 
drainage, is most effectual; so, also, is Apostolus method of intro- 
uterine raclage, which is the galvanic current of electricity applied to 
the fundus of the uterus with a suitable carbon electrode of proper 
size to fit the endometrium. The positive pole is placed over the 
subpubic region, and the negative pole in the uterus ; the current is 
applied for seven minutes to the endometrium, or fundus, and then the 
electrode is brought down to the junction of the cervix and applied the 
same length of time. The operator may give from ten to twenty milli- 
amperes aseptically each time, and every third day for four or Rye 
times. To the cervix may be applied Churchill's tincture of iodine, 
or dry dressing of boric acid and bismuth, with antiseptic gauze packed 
around the uterus. This method has been most successful in the 
writer's hands. 

Regulations of the Lying-in. — The length of time necessary for 
rest after labor varies with different women. During the first week 
she ought not to leave her bed. Ordinarily, with strong, robust 
women, they can rise partly or fully to the sitting posture for micturi- 
tion ; this favors, also, the expulsion of blod-clots. Throughout the 
second week the patient, if robust, may recline on a lounge, provided 
involution is going on properly; during the third week a portion of 
her time may be spent in an easy-chair. She should not be allowed on 
her feet until after the third week. A very delicate woman should not 
sit up at all till the end of the second week, and not then if involution 
is retarded from the enfeebled condition of the general system ; she 
should take the rest-cure for at least six weeks, till her constitution is 
restored to its normal condition. 



Maternity. 703 

CAKE OF THE NEW-BORN INFANT. 

Immediately upon the birth of the child's head, its face, should 
opportunity permit, should be bathed with warm water ; the eyes espe- 
cially should be be cleansed and carefully dried before the child is even 
separated from its mother. This is done as a preventive against 
ophthalmia. As a still further preventive, within a half hour or an 
hour after birth, the eyes should be washed with boracic-acid solution, 
about Hye grains of boracic acid to one ounce of boiling water; first 
wipe the eyes and drop into them enough to wet them; one or two 
drops are sufficient, or wet a cloth and lay over the eyes for a few 
moments at a time. A one per cent solution of nitrate of silver is 
recommended as a prophylactic against ophthalmia ; after bathing the 
eyes in warm water, drop in one or two drops once a day for a few 
days. Should this treatment cause a serous oozing, it may be promptly 
controlled by a single application of a drop or two of a one-half per cent 
solution of the sulphate of atropine. 

Ligation of the Cord. — The ligation of the umbilical has been 
alluded to. The common practise is to tie from one and a half to 
three inches away from the umbilical; place the second ligation about 
three-quarters of an inch from the first one; both are to be tied as 
tightly as it can be drawn, with care to put no strain on the umbilical 
insertion. Before tying, pinch the cord very firmly, or strip it back 
towards the mother with the left fingers, while with the right hold it 
firmly so as to thin the cord should it not be a thin one already, because 
this prevents or lessens the danger of hemorrhage from the umbilical. 
The tape should be from one-fifth to three-fourths of an inch wide, and 
should be dipped in boiling water beforehand, and should be damp 
when it is used, to prevent it from slipping when tied. With clean 
scissors cut the cord between the two ligatures. Press the stump with 
a soft, clean cloth, to be sure there is no bleeding. Usually respiration 
is promptly established at birth. When the new-born infant does not 
breathe properly soon after birth, means should be employed to secure 
the full expansion of the lungs. Useful measures for this purpose 
are blowing forcibly upon the face, dashing a few drops of cold water 
upon the chest or the face, or gently slapping the buttocks with the 
hand. The efforts should be continued until the child cries lustily. 
When respiration is obstructed by mucus in the throat, the offending 
material may be removed by the finger wrapped with a soft rag. Sus- 
pending the child by the feet a few moments facilitates drainage of 
liquids from the air passages. 

Care must be taken to protect the child from chilling. It must 
be carefully wrapped in warm flannels, and, as soon as the cord is cut. 
laid in a warm place until the necessary attentions to the mother are 
completed. While it is moist, the head should be covered, as well as 
the trunk and limbs. Inspect the navel cord occasionally to see that it 
does not bleed from loosening of the ligature as the stump shrinks. 



704 Maternity. 

Bathing. — The first bath, if the child is robust, may be given soon 
after it is separated from its mother; if feeble, the bath should be 
postponed for several days. In the latter case, inunctions of sweet-oil, 
vaseline, or fresh cocoa butter are to be substituted for the general 
bathing. As a preliminary to the first cleansing, the skin is to be 
well rubbed with sweet-oil or some fatty material to facilitate the 
removal of the vernix caseosa ; then wipe the child clean ready for its 
bath. 

If the weather is cold, the toilet should be made in a warm room, 
preferably in front of an open fire or grate. It must not be forgotten 
that a child, until the moment of its birth, has always been in a tem- 
perature of 98° to 100° Fahrenheit, and that any prolonged exposure 
to cold after birth may be followed by disease and even death. The 
nurse should have on hand, and within easy reach, a cup of clean cold 
water, a large basin of hot water, from 100° to 105° Fahrenheit, also 
have old white castile soap, a teacup of fresh hog's lard or a bottle of 
olive-oil, and soft wash rags ; old muslin is as good as old linen for the 
purpose. 

Sitting in front of the fire, the babe is turned upon its back, and 
the toilet begun and conducted as follows: The nurse should begin at 
the mouth, and, with a clean rag over her finger, wash it out. After 
cleansing the mouth thoroughly, you may give the child a few drops 
of water or a little warm sweetened water, by letting it suck from a 
piece of clean rag or from a teaspoon. The next step is to remove the 
sebaceous matter from the child's skin. Take a piece of old flannel, 
and, keeping the child well wrapped in its covering, begin at the head, 
and rub the surface briskly with oil or lard; instantly the sebaceous 
coating disappears, dissolved by the lard or oil. The capillary circula- 
tion is stimulated by the brisk rubbing, and becomes active, the surface 
becoming a bright red color. Similar application must be given to 
the rest of the body. Now give the bath in a systematic way, keeping 
the body well covered and beginning at the head. The hot water, with 
plenty of castile soap, soon removes the oil and sebaceous matter; be 
careful not to get any soap about the eyes. 

Conjunctivitis in the new-born child may be due to other causes 
than the acrid secretion of the maternal parturient surfaces. Among 
these causes are exposure to cold, to too bright light, and last, but by 
no means least, the careless application of soap to the eyes during the 
first bath. After the head is washed and carefully dried, the same 
application is made to the whole body, the child still kept covered save 
the part undergoing the cleansing process. Speedily the parturient 
soilings are all removed, and the infant is then ready for its grand and 
final hot bath (not too hot). For this purpose, it is best to have a 
large wash-basin or a bath-tub containing clean hot water, temper- 
ature 100° to 105° Fahrenheit; into this hot bath the whole body of 
the infant save its head is now to be immersed, and the bath prolonged 



Maternity. 705 

from a minute to two or three minutes until the child is thoroughly 
rinsed. In this last bath the child usually cries vigorously, which is 
beneficial in completely establishing the respiratory function and stim- 
ulating the general as well as the capillary circulation. On removing 
the infant from the bath, it should be wrapped in a small, hot, soft 
absorbing towel (Turkish towel is the best), and gently and thoroughly 
dried. The nurse should now change the apron she has worn during 
the bath for a fresh, dry one, before dressing the infant. 

Dress the cord by enveloping the stump in some soft, clean, boiled, 
absorbing material, usually some old linen or muslin rag; antiseptic 
gauze is preferable for dressing the stump, but a simple dressing that 
an uneducated person may perform is the main object I want to 
impress upon the country nurses, who have not had hospital training, 
as we never know when you may be called upon to perform this need- 
ful work. The most simple dressing is, roll up the stump of the cord 
until about four thicknesses of the cloth cover it; tie a soft string 
around the covering, bring the covering well up against the belly ; now 
wet the covering with sterilized olive-oil, and fold another piece of 
cloth about the width of your hand (two thicknesses will do), and 
place it over the cord, turning the cord to the left towards the chin; 
then apply the bandage. Some writers recommend adhesive plaster 
for fastening down the cord. 

The bandage should be made of flannel, wide enough to reach from 
the hips to the axilla, and long enough to go twice around the child's 
body; it should not be hemmed. After turning the cord towards the 
chin, you will now secure the bandage with small safety-pins. Be 
careful not to apply the bandage too tightly, but as loosely as is con- 
sistent with its use. Then put on the clothing; baby powder may be 
used freely. A child properly washed and dressed will sleep imme- 
diately after its toilet is made. If it should cry, undress it, and see 
that there are no wrinkles or anything too tight. See that the infant's 
feet and hands are warm : when the doctor arrives, he will examine 
for all defects. 

If the mother has recovered sufficiently from the fatigue of labor, 
it should be put to the breast; indeed, this early application to the 
breast is so very desirable for both mother and child that no ordinary 
circumstances should be permitted to postpone it. For the mother it 
is valuable in securing prompt and continued contraction of the uterus, 
thereby preventing post-partum hemorrhage and after-pains. Should 
the child not be put to the breast for any reason, it may be given a 
teaspoonful of warm sweetened water, and then be placed in a cradle 
on its right side, well covered (the face not too closely), and out of all 
draughts. It should be protected from exposure to all bright lights, 
and the surrounding atmosphere should be as clean and pure as pos- 
sible. 



45 



CHAPTER LVL 
NASAL OBSTRUCTION. 

"We are told in Genesis, that when God made man, it was not 
into his month, bnt into his nostrils, that He breathed the breath of 
life. The disastrous consequences to the organs of respiration, audi- 
tion, and voice production from occlusion of their natural atmos- 
pheric channels, are too often lost sight of by those who, unmindful 
of this truth of scriptural physiology, sum up the varied functions 
of the nasal apparatus in the terse proposition, The nose is the organ 
of smell. 

a The influence of nasal obstruction in the causation not only of 
morbid conditions of the whole respiratory tract and middle ear, but 
also of pathological changes in other and more remote organs of the 
body, is no longer a matter of interesting speculation, but is grounded 
on the firm foundation of every-day clinical fact and experience. The 
removal of nasal obstruction in young children is of special importance ; 
for in them it means interference with the act of suckling and con- 
sequently with the maintenance of life." (J. Eoland McKenzie.) 

Obstruction of the nasal fossae may be acute or chronic. We will 
speak especially of the chronic form. The lumen of the nasal pas- 
sages may be congenitally narrow enough to interfere seriously with 
respiration, and it was this congenital anomaly, doubtless, of which 
Sylvaticus wrote over two centuries ago. 

The nasal passages are much more frequently the seat of con- 
genital abnormalities than the pharynx. The inference from history 
is that malformations of the naso-pharynx are of rare occurrence, 
because of the little mention made of them in works on teratology, 
and the infrequency with which isolated cases are encountered in 
periodical medical literature. Pliny the Elder tells us that children 
born in the seventh month frequently have the ear and nose imper- 
forate. It is observed that whether the natural historian is correct 
or not, it is quite certain that occlusion of the posterior nares is the 
most common of congenital nasopharyngeal anomalies. The occlu- 
sion may affect one or both nostrils, and may be membranous or bony. 
The orifices of the posterior nares may be alone implicated, or the 
nasal fossae may be obliterated in their entirety. 

Effects of Nasal Obstruction. — The evil effects of nasal obstruc- 
tion may be felt in almost every organ of the body. So important 
is a proper discharge of the nasal functions, not only to the structures 
directly involved, but also to the general welfare of the individual, 
(706) 



Nasal Obstruction. 707 

that the abrogation or suspension of the vital properties of the intra- 
nasal tissues may be looked upon as one of the most serious obstacles 
to the enjoyment of physiological life. This is especially true in 
early childhood, when growth and development are going on with 
rapidity, and when the demand for healthy respiration is accordingly 
all the more imperative. The bad health and stunted growth of 
children suffering from nasal obstruction are matters of e very-day 
occurrence, unfortunately too frequently overlooked. (J. N. McKen- 
zie, M. D.) 

Xasal obstruction in children is the fertile source of many incur- 
able respiratory and aural affections in after life. In nasal obstruc- 
tion is a predisposition, other things being equal, to inflammatory con- 
ditions of the respiratory tract. Chronic inflammations have been 
induced in the bronchial and pulmonary mucous membrane, which 
are very difficult to deal with, even after the original cause has been 
removed, and the practical physician can not afford to overlook the 
influence which nasal obstruction exerts in their production. In this 
country the vast majority of cases of chronic laryngitis originate 
primarily in disease of the nose, and many a winter cough is allowed 
to go on from bad to worse because of failure to recognize this rela- 
tionship. 

It is thought, furthermore, that nasal obstruction may and does 
cause diseased states of the lungs, and in an individual so predis- 
posed, may favor the development of pulmonary consumption. Frankel 
states that emphysema frequently coexists with nasal stenosis, and 
Kussmaul believes that acute hyperemia of the lung may be produced 
by forced inspirations of air. Frequently mucus and subcripitant 
rales can be heard in different portions of the chest. 

Besides the part which the nose plays in the processes of olfac- 
tion, respiration, and voice production, it also serves as the channel 
of conduction of atmospheric air to the middle ear. The aural 
pressure is kept in a state of stable equilibrium by the constant sup- 
ply of air to the cavity of the drum through the Eustachian tube. In 
the natural state this ventilation of the tympanum is continually tak- 
ing place, not only as the result of the partial vacuum created in the 
nasopharynx during the act of deglutition, but also during normal 
nasal respiration. It follows, therefore, that anything which tends 
to obstruct the passages of air through the nose will interfere, to an 
extent varying with the amount of obstruction, with normal aural ven- 
tilation, and consequently with physiological intra tvmpanic pressure. 
This diminution of pressure within the cavity of the drum, which 
can readily be demonstrated experimentally, leads necessarily to inward 
collapse of the membrana tympani, with consequent abrogation of 
function in the osseous and muscular apparatus of the middle eor. 
Catarrhal otitis-media, with its long train of phenomena, is the inevit- 
able result. Fluid not infrequently accumulates in the tympanum, 



708 Nasal Obstruction. 

which finds an exit ultimately by perforation of the membrane and 
leads to chronic otorrhoea. This same chain of events follows the 
obstruction of the Eustachian tube by growths in the pharynx, or the 
pressure of the hypertrophied nasal turbinated structures, or by inflam- 
matory engorgement of the orifice of the tubes themselves. This cuts 
off the air supply from the tympanum, not only by direct occlusion 
of its natural channel, but also by interfering with the motions of the 
velum, and therefore with the opening of the tube by the tensor 
palati, or dilator of the tube. The intimate and direct connection 
of the blood supply of the tube and pharynx with that of the middle 
ear, and their anatomical continuity of tissue, favor, furthermore, 
the 4 extension of the inflammatory process from the one to the other. 
Indeed, in very many cases the aural inflammation is merely a symp- 
tom of nasal catarrh, and gradually disappears without special treat- 
ment, upon the removal of its primary cause. 

Inflammation of the tube may result in stricture ; and in long- 
standing cases of salpingitis, fatty degeneration of the tubal muscles 
occurs, with the consequences described above. 

These are by far the most common causes of chronic catarrhal 
inflammation of the middle ear. It is said to be impossible to exag- 
gerate the part which diseases of the nose play in the production of 
inflammatory conditions of the middle ear. Between sixty and seventy- 
five per cent of all cases of ear disease originate primarily in mor- 
bid states of the nasopharynx, and the successful treatment of middle- 
ear catarrh will in the vast majority of instances depend upon their 
recognition and removal. The most common result of obstruction 
of the nasal passages is inflammation of the nasal pharynx. Exten- 
sion of the inflammatory process into the ethmoid cells is also met 
with. Obstruction of the nasal duct is an occasional complication. 

There is one symptom of nasal obstruction to which especial 
importance must be attached, and for which alone the physician is 
often consulted. Dyspnoea on exertion is one of the most annoying 
features of the case. Such patients complain that in talking they 
must frequently pause for breath; that in going up-stairs, walking 
rapidly, or running, — in short, in all bodily operations in which 
unusual exertion is required, — they readily get out of breath. Dif- 
ficulty seems also present when the mouth is* occupied or closed, as 
in swallowing, smoking, etc. Hemorrhage from the nose is not an 
uncommon symptom of nasal obstruction. It is usually excited by 
picking, scratching, rubbing, or blowing the nose, or by sneezing or 
coughing, by the separation of crusts, etc., that determine an increased 
flow of blood to the nasal membrane. 

Sometimes such hemorrhages occur at night, from unconscious 
irritation of the nose with the finger during sleep. 

The symptoms of advanced nasal obstruction have been well 
described by Meyer and others. The pallid countenance assumes a 



Nasal Obstruction. 709 

dull, stupid expression, and the cheeks become flabby from elonga- 
tion of the nasolabial sulci. The mouth is kept open, and the lower 
jaw depressed; the gums are fissured and cracked, and saliva drib- 
bles from the mouth. Deafness and tinnitus are nearly always pres- 
ent. Neuralgia is common. Taste is impaired. The nasal discharge 
is profuse, excoriating the nostrils, filling the pharynx, preventing 
sleep, and provoking suffocating attacks. 

These symptoms, with constant snuffling, are well marked among 
children and react most powerfully upon the general health. Later 
in life the nostrils become abnormally narrow from arrested develop- 
ment or collapse of the aire nasi. The speech becomes nasal, the 
tone of the voice dull and "dead." (Meyer.) Obstructions in the nasal 
fossae (polypi, etc.) prevent the free passage of the voice, and dimin- 
ish accordingly the force of tone. All such obstructions as polypi and 
foreign bodies are removed by some form of surgery. Nasal polypi 
are not found in young children. 

Reflex cough arises most frequently in the nasal passages. Of 
late years the nasal reflexes have been exhaustively studied by investi- 
gators in rhinology, and the wonderful revelations incident to these 
investigations have enabled us to appreciate the far-reaching and com- 
plex character of the influence emanating from this sensitive region. 

The cough-center in the brain is said by Kohts to lie "on each 
side of the raphe in the neighborhood of the ala cinerea." Coughing 
is produced by stimulation of the sensory fibers of the vagus distributed 
to the mucous membrane of the larynx, trachea, and bronchi, the 
portion of the nasal chamber which is designated as "respiratory tract" 
is given as that in which the reflex acts of coughing arise. 

The most sensitive parts of this respiratory tract are found where 
erectile tissue is most abundant, and particularly over the posterior 
portions of the lower turbinated bodies and septum. 

It is said that by far the most common pathological state in which 
cough is produced is that of catarrhal inflammation, in the form either 
of acute coryza or of chronic hypertrophic rhinitis. Under such cir- 
cumstances we have all conditions active for the reflex manifestations. 
The varieties of reflex irritation we will not discuss, except that of 
nasal cough. In the inflammatory conditions the sensory disturbances 
are readily induced, and cough excited either from hyperemia, hyper- 
trophy, or naso-motor disturbances, from irritants without, or from 
internal excitants, such as secretion or contact of swollen tissue, etc. 

It is a Avell-known fact that a small pledget of cotton or a delicate 
probe introduced into the nasal chamber, in contact with certain areas, 
and in certain subjects, will cause a reflex act expressed by a cough. 
The production of nasal cough is of so great interest and clinical 
value in affections of children that one ignoring it, or neglecting to 
appreciate its true position in the successful management of many 



710 Nasal Obstruction. 

affections of childhood, will often find the most vaunted remedies of 
no avail. 

One of the most frequent and troublesome reflex coughs met with 
in children is the "night cough/' a cough of nasal origin. Vogal 
speaks of it as a "periodic nocturnal cough." Nocturnal cough in 
an infant or child, without pulmonary implication, occurring toward 
midnight, the child being in the recumbent position, is almost certain 
to depend upon a catarrhal inflammation seated in the nasal passages 
or nasopharyngeal cavity. After the child has been asleep for several 
hours, an accumulation of secretion in the nasal chamber takes place, 
and turgescence of the posterior erectile tissue will be present. In 
the erect position this accumulation would be expelled from the nos- 
trils or swallowed ; but while lying down asleep, it will naturally take 
the direction of gravity, and lodge in the posterior nares upon the 
most sensitive areas, and from contact alone or upon movement of the 
mucus, produce an irritation sufficient to cause a cough ; this cough 
is short, dry, irritative, and most persistent and intolerable. When 
this mucus is expelled, the child falls asleep and no further cough 
ensues until the following night. So long as the coryza continues, 
the cough may be produced. 

Follicular pharyngitis, acute and chronic, often seen in children, 
gives rise to a reflex cough. This is generally a disease secondary to a 
chronic nasal catarrh. The enlarged follicles are often not only pain- 
ful, but also very susceptible to irritation. Frequently the passage 
of air over these inflamed structures will produce a short, dry cough. 
Hypertrophy of the tonsils, so common in childhood, with many other 
symptoms, produce a cough which at times takes the form of suffo- 
cative attacks, and is paroxysmal. An elongated and inflamed uvula 
sometimes causes cough in children by mechanical irritation of the 
Base of the tongue, though this is not a frequent condition in early life. 
Enlarged lingual papilla? or lymphoid tissue situated at the base of 
the tongue, when present in children, occasions a most obstinate dry 
cough, when this hypertrophied tissue interferes with the play of the 
epiglottis and irritates its lower surface. This condition, too, accord- 
ing to my experience, is not frequent in children, though common in 
adults. 

Ear cough is uncommonly present in certain conditions of the 
auditory meatus and membrana tympani. This ear cough can be pro- 
duced by irritation set up in the auditory meatus by accumulation of 
wax, when the serum is unusually dry and loosely confined in the ear. 
(Dr. J. C. Blake.) We see cases recorded of foreign bodies being 
removed from the ear, and the reflex cough disappears like magic. 

Cough produced by irritation of the fibers of the vagus distributed 
to the alimentary canal has been called stomach cough. Undigested 
or indigestible articles of food remaining in the stomach have produced 



Nasal Obstruction. 711 

cough, and the reflex phenomenon disappeared only when the stomach 
had ejected its contents. 

Treatment. — The surgical measures for the removal of nasal 
polpi are three in number, viz., evulsion, abscission, and the galvano- 
cautery. Of these, evulsion with the forceps is by far the oldest 
method and the one most generally practised. In all cases the polypi 
should be removed by the aid of the rhinoscopic speculum or mir- 
ror, care being taken not to work in the dark. All such cases should 
be treated by a specialist of some experience. 



CHAPTER LVIL 
RHINITIS (NASAL CATARRH). 

Definition. — This is a chronic affection of the nasal passages, 
hypertrophy of the pituitary membrane. These are hypertrophic 
tumors of the nose, and most often encountered in the young. 

*! Treatment. — The galvanic current of electricity, applied with 
a platinum needle. After cocaining the parts, the positive pole is 
used at the base and the negative passed through the apex of the 
growth; give milli amperes enough to turn the growth to a blanched 
appearance, then reverse the current a moment so as to admit the 
removal of the positive needle without tearing the tissues. Usually 
one or two treatments effect a cure in the writer's hands. In all 
cases, tonics of iron and strichnse are useful, also cod-liver oil, and 
occasionally an alterative for the liver aids in general nutrition. 
After the treatment, some bland antiseptic oil is necessary for the 
comfort of the patient. Carbolated vaseline is very good. 

Extirpation is the treatment when the galvanic needles are not 
used, to overcome nasal stenosis. 

The most important measures when the galvanic current is not 
available are the snare, ligature excision (with scissors), and dis- 
integrating injections. The child should be treated as soon as the 
disease is observed. The symptoms of chronic rhinorrhoea in infants 
are inability of sucklings to take nourishment, attacks of suffocating 
.spasms from obstructed respiration, habitual mouth breathing, con- 
stant sneezing; and in children, frequent complaint of headache and 
earache, nasal cough, constant raising and expectoration of ropy 
mucus, inability to breathe through the nose, especially during the 
night, with consequent disturbance of rest, dryness of the throat, 
and mental inaptitude. 

When surgical measures can not be employed, various lotions 
may have to be tried for relief of infant. I have employed a lotion 
of linseed oil and spirits of turpentine with satisfactory results. It 
has the advantage of being cheap, so that every household can have 
it ready at hand for use in case of an acute coryza. 

Ijfc: Spt. turpentine 3j to iss 

Olium linseed 3vi to Jviij 

Misce. 

May be used with a small swab of cotton wrapped around the 
end of a burnt match or small probe of some kind. Or, if the child 
is too young to sniff the lotion, a dropper may be employed to pass 

(712) 



Nasal Catarrh. 713 

a few drops into the nostrils three times a day. ^asal lotions are, 
of course, always warmed before using. A variety of nasal lotions 
are in use, among which may be mentioned bicarbonate, biborate t 
benzoate, phosphate, and chlorate of sodium, in the proportion of 
from one to five grains to an ounce of fluid. These bland, unirri- 
tating salts of sodium are usually employed in solution with glycerine 
and a mere trace of antiseptic agent, like menthol, peppermint, 
salicylic acid, benzoic acid, carbolic acid, or bichloride of mercury. 

Astringents are of doubtful efficacy to the pituitary membrane. 
These lotions should be very weak; with a post-nasal syringe flush the 
nasal cavities. 

These local measures will naturally have to be combined with 
appropriate treatment of the effects of complications of catarrhal 
processes commonly observed in the ear, eye, pharynx, larynx, and 
throughout the system, as manifested by constitutional depression, 
nervous disturbances, and derangement of the various viscera. 

CROUPOUS RHINITIS. 

Croupous rhinitis follows the rule observable in all classes of 
diseases of the upper air passages characterized by the superficial 
deposit of fibrinous exudation, in that its onset is attended with 
well-marked evidences of general disturbance. In most cases the 
invasion is attended with a chill, although in many cases there is 
merely a chilly sensation. This is followed by general febrile motion. 
The thermometer, as a rule, on the first day will show a temperature 
of 102° to 103° Fahrenheit. The higher temperatures are not usually 
observed in the nasal disorder. In connection with the fever there is 
usually pain in the back, headache, depression of spirits, and the 
train of symptoms which are embraced under the expression general 
malaise. 

Diagnosis. — Sneezing and watery discharges indicate, apparently, 
a cold in the head. This is soon followed by the development of the 
croupous membrane. The progress is very rapid, so that at the end 
of twenty-four to thirty-six hours it extends throughout the nasal 
cavity, resulting in complete stenosis, or closing up of the nasal 
cavity. In these cases it will be necessary to carefully wipe away 
the accumulation for the thorough inspection of the part; for it is a 
matter of importance that the condition should be recognized, and 
it should always be suspected in cases of an apparently ordinary 
acute rhinitis attended with marked general disturbance and high 
febrile motion. Very careful manipulation is necessary in removing 
the secretion, and careful inspection of the cavity with a good light, 
the reflected rays of the sun being always preferred as the source 
of illumination. On delicately manipulating the probe, it will be 
found that the false membrane can be lifted from the surface of the 
mucous membrane beneath, which then will be found absolutely 



i 



714 Nasal Catarrh. 

intact. In other words, the removal of the false membrane is attended 
with no rupture of blood-vessels, as is characteristic of the diph- 
theritic membrane. 

Local Treatment. — The tendency after removal of the mem- 
brane is to a redevelopment. To prevent this we have no sin- 
gle drug which possesses the promptness and efficacy of the prepara- 
tions of iron, and of these the tincture of persulphate may be used 
in full strength, provided the application is made with that nicety 
and delicacy of manipulation by which the unpleasant action of these 
drugs on the healthy structure may be avoided. Remove the mem- 
brane by a small cotton pledget on the end of the probe, care being 
taken to do no injury to the membrane beneath, the point being that 
if blood-vessels are ruptured, a certain danger arises of absorption 
of morbid material, which is always to be carefully avoided. After 
the membrane has been removed, the inflamed surface beneath should 
be carefully brushed over with small pledgets of cotton soaked in 
either persulphate or tincture of iron. This manipulation is to be 
repeated daily, or twice daily, until the morbid process is brought 
fairly under control. Where the exudation is a thin, continuous 
membrane, it is better to apply the tincture of iron over the mem- 
brane, as the iron checks the activity of the membrane as it destroys 
all activity in fibrinous deposits. 

General Treatment. — The systemic condition in these cases is 
one of hyperinosis, and tincture of iron has the most controlling 
influence in this condition. Hence in all cases of croupous rhinitis, 
iron should be given for its systemic action. 

1>: Tinct. ferri chloride 5ij 

Glycerine ad |ij 

Mix. 
Sig. : A half teaspoonful every four hours. 

In addition to this, and especially in young children, mercurials 
unquestionably possess a certain power in controlling a fibrinous exuda- 
tion. Hence they should be administered in pretty full doses in 
connection with the iron, until their action has been thoroughly tested. 
For this purpose the mild chloride: — 

I/: Hydrarg chloridime mite grs. xx 

Sacch. lact. ad Sii 

Sodae bicarb grs. xx 

M. et div. in chart. No. 40. 
Sig. : One to be given every four hours to a child, till three doses 
have been administered ; eight hours after the last dose, castor-oil 
may be given to move the bowels. For adults, two powders may be 
given every four hours. Castor-oil may be given when necessary 
to move the bowels, while the syrup of rhubarb is administered as 
necessary for a laxative. 



Nasal Catarrh. . 715 



RHINITIS ATROPHICA, CHRONIC. 



Definition. — Dry nasal catarrh is a chronic affection of the nose 
characterized by the shrinkage, or atrophy, of the pituitary membrane, 
without ulceration, and accompanied with the formation of mucus 
or mucopurulent crusts, which, as a rule, give rise to an offensive 
odor. 

Diagnosis. — The distinguishing structural features of atrophic 
rhinitis are smoothness of the pituitary membrane, loss or reduction 
of the turbinated bodies, abnormal spaciousness of the nasal cham- 
bers, shrinkage of the adenoid tissues in the vault of the pharynx, 
and pharyngitis sicca. 

The secretory peculiarities are the formation of crusts and nasal 
molds, pronounced fetor of the nasal discharges (ozsena), and marked 
diminution and thickening of the secretions. The most prominent 
symptoms are a sensation of dryness, nasal obstructions from 
the accumulation of scabs, headache, a stench compared by the French 
to that of crushed bedbugs, excoriations, and sometimes hemorrhagic 
abrasions caused by scabs. 

Treatment. — The measures adopted for local treatment of the 
affection, are, first, the loosening and removal of the intra-nasal incrus- 
tations and thickened secretions ; second, the prevention of the return 
of these conditions and the maintenance of the nasal chambers in a 
state of asepsis ; and, third, the improvement of the general health. 

There are various kinds of antiseptic solutions used by spe- 
cialists, such as carbolic acid to the ounce of water, gr. % to 3; 
salicylic acid, gr. 1 to 4 ; salicylate of sodium, gr. 5 to 10 ; sulpho- 
carbolate of zinc, gr. ss to 2 ; solution of salt (chloride of sodium), V2 
dram to 1 dram ; benzoic acid, gr. % ; benzoate of sodium, gr. 1 to x ; 
thymol, gr. % to 1 ; permanganate of potassium, gr. 1 to 4 ; and 
bichloride of mercury (1 to 10,000). The proportion of each of the 
agents will, of course, vary with the condition of the patient to suit 
each individual case. Glycerine, when employed in conjunction with 
these antiseptic nasal washes in the proportion of from fifteen minims 
to a dram to the ounce, will be found to be a most valuable agent 
in promoting the removal of crusts, by its softening and solvent action, 
and soothing the irritated and oftentimes inflamed mucous membrane. 
Furthermore, the washes should be employed at a comfortable tem- 
perature, about blood heat or a little more. 

The quantity of liquid should be copious, in order to remove 
crusts, and the douche should be used with some little force to pro- 
ject it effectively through the nostrils. A hard rubber postnasal 
syringe is to be preferred. Parents should be instructed how to 
use the postnasal syringe, and the nasal chamber should be washed 
out at least twice daily, namely, morning and evening. 

Vaseline, lanoline, lard, cocoa butter, and gelato-glycerine are all 
suitable agents in loosening up crusts in the nasal cavity; and some 



716 Nasal Catarrh. 

one of these lubricants should be used after using the douche; these 
remedies may be applied with a cotton swab or with a feather. 
Vaseline dissolved is easily sprayed into the intranasal cavity. 

Linseed oil 4 ounces, spirits of turpentine 1 dram to 1% dram, 
is a very efficient lubricant. The writer has used it in preference 
to all other lubricants. 

The writer has used the galvanic current of electricity for 
loosening up the crusts in chronic rhinitis. A small aluminum wire 
is insulated with rubber nearly to the end of the wire, and a bit 
of absorbent cotton twisted firmly around the end of the wire — not 
too much cotton — this is dipped in a 20 per cent solution of cocaine. 
Aiter having attached this wire to the positive pole rheophore, also hav- 
ing placed the negative electrode over the chest, pass the wire gently 
into the nasal cavity over the crusts, and let it remain from one 
to two minutes over each affected part of the nares till the entire 
cavity has been acted upon. From five or ten to fifteen milliamperes 
may be given, according to the chronic condition of the case. Treat 
each side the same. After the seance, apply the linseed oil and tur- 
pentine lotion. The galvanic current should be used twice or three 
times a week till the case is cured, or after all crusts cease to form in 
the nasal cavity; once every four days is often enough to use the 
electricity. The linseed lotion must be used night and morning daily 
till a cure is effected. 

Constitutional treatment is necessary. Syr. hypophosphites ; 
Glide's pepto^mangan ; Wyeth's elixir of iron, quinine, and strychme; 
and Wampole's cod-liver oil, should be employed alternately, that is 
to say, take Gude's pepto-mangan for two months; after resting a 
couple of weeks, take Fellow's syrup of hypophosphites for six weeks ; 
then use Wampole's cod-liver oil for two or three months till well, 
etc. 

PURULENT RHINITIS OF CHILDREN. 

In examining the literature on the subject, F. H. Bosworth, 
M. D., defines the term used to designate a form of catarrhal disease 
which is met with exclusively in young children, and is characterized 
mainly by a more or less profuse secretion of muco-pus from the 
nasal passages. Mackenzie 1 confines the use of the term to the acute 
form met with in infancy, and usually attributed to infection from 
the genital passages of the mother, although he questions the accuracy 
of this view; while under the chronic form he 2 would seem to refer 
to that curious affection first described by Stoerck as occurring as a 
local disease among the Poles, which consists in the development of 
a purulent discharge, mainly as the result of uncleanly habits, — a dis- 
ease which runs an essentially chronic course, and is said to extend 
to the lower air passages, giving rise to dyspnoea, in one case trache- 
otomy having been required. 

1 "Diseases of the Throat and Nose," vol. 11, p. 294. 
*Loc. cit., p. 335. 



Nasal Catarrh. Ill 

According to Bosworth, "purulent rhinitis is essentially a chronic 
disease, and runs an exceedingly protracted course, extending over 
from five to fifteen years, in all cases probably commencing in child- 
hood. Its essential feature then consists of a rapid cell prolifera- 
tion, resulting in profuse cell desquamation." 

Causation. — The disease is said to be essentially a local one, and 
is in no way connected with any peculiar diathetic condition, nor is it 
the result of impairment of the general health. We simply say, 
then, as regards causation, that it is probably due to some errors in 
hygienic surroundings, — insufficient clothing or improper diet, — which 
lead in child life to a habit of taking cold, which at this time of 
life, as we have seen above, tends to manifest itself in the peculiar 
form of inflammation. 

Undoubtedly in many cases it has its origin in an attack of 
measles, scarlet fever, or some of the other forms of exanthemata, 
which are frequently attended with catarrhal inflammation of some 
portion of the upper air passages. 

Diagnosis. — A diagnosis in these cases is of the greatest impor- 
tance, in view of the fact that if the disease runs on to the stage 
of crust formation, or ozena, we have to deal with an affection usually 
not amenable to treatment. Syphilitic or scrofulous disease of the 
nose is attended with pus discharge, the result of ulceration and 
necrosis. 

In these cases the discharge, therefore, would be mingled with 
masses of black necrotic tissue, or portions of bone, which would be 
at the same time attended with an intolerably offensive odor that 
could never by any possibility be mistaken for the odor of simple 
purulent rhinitis. In addition to this, there would be the othe^ 
evidences of poison in the system, such as a general cachexia, skin 
eruptions, or other syphilitic symptoms. Moreover, syphilitic disease 
of the nose is usually unilateral, while the affection of purulent r 1 
nit is is always bilateral. Young children are exceedingly prone to 
insert small bodies into the nostril, but usually the child contents 
itself with inflicting this injury upon one nostril. The prominent 
symptom of the disease consists of a discharge from both nostrils 
of a somewhat clear, yellowish, thick, mucopurulent catarrhal secre- 
tion, which shows a disposition to form crusts in the lower portior 
of the anterior nares, or unsightly accretions around the margin of 
the nostrils at the muco-cutaneous junction. If the child is old enough 
to use a handkerchief, the discharge expelled stains the linen a 
bright yellow. If it remains in the nasal passages, it accumulates 
in such a way as to give rise to notable stenosis. During an acute 
exacerbation the amount of discharge is increased, while at the same 
time the mucous membrane is notably swollen, and the nasal stenosis 
markedly increased. In fact, the child suffers from an ordinary acute 
corvza. 



718 Nasal Catarrh. 

If we make an examination anteriorly, we find the mucous mem- 
brane congested and of a dark-reddisli color. The membrane is cov- 
ered with flakes and masses of yellowish mucus, coating the lower 
turbinated bones and lying in masses on the floor of the nares. An 
examination of the pharynx, also, will usually show that the secre- 
tion has made its way to this region, and hangs down in shreds 
between the pharynx and soft palate. The source of this, of course, 
might be in an enlargement of the pharyngeal tonsil. 

Course. — The disease commences at from three to six years of 
age, and runs a course of about ten or eleven years, before the crust 
formation sets in. 

£ Treatment. — This is one of the diseases which is thoroughly 
amenable to local treatment, and that of an exceedingly simple char- 
acter, the essential feature being that the cavity shall be thoroughly 
cleansed and sprayed with some simple astringent. For cleansing 
purposes one of the following is recommended : — 

#: Acid carbol ... grs. iii 

Sodii bicarb grs. xii 

Sodii biborat 3ss 

Glycerini 3 vi 

Aquse ad 3vi 

Mix. 

I>: Listerini ^ss 

Sodii biborat 3ss 

Glycerini 3vi 

Aquie ad 3 vi 

Mix. 

#: Thymol HI xx 

Sodii chloride 3ss 

Sodii benzoat grs. xx 

Aquse ad ^vi 

Mix. 

$: Echthyol gr. i 

Potassii chloridi 3ss 

Liquor calcis ad I vi 

Mix. 

This should be applied twice or three times a day if necessary 
by the means of some simple hand atomizer, the spray being thrown 
repeatedly into one and then into the other nostril, the child being 
directed to blow the nose thoroughly after the application until the 
parts are thoroughly cleansed. In very young children it may be 
necessary to use the nasal douche, which requires no effort on the part 
of the patient, possibly to employ a simple ear syringe. After the 
parts have been well cleansed, an astringent should be used as follows :— 



Nasal CataiTh. 719 

1/: Zinci sulpbo-carb . . .gr. xx 

Hydrarg chlor. corros gr. \ 

Aquae, ad ^iv 

Mix. 

t>: Acid borac 3ii 

Aquae, ad giv 

Mix. 

t>: Acid salicylici gr. vi 

Aquae, ad %iv 

Mix. 
To either of the above may be added with benefit any of the 
simple astringents, snch as glycerole of tannin, 1 dram to the ounce; 
orgenti nitratis, 3 grains to the ounce; yinci sulphatis, 3 grains to 
the ounce; cupri sulphatis, 2 grains to the ounce; aluminum aceto- 
tartrate, 10 grains to the ounce. 

As before stated, the disease is purely a local one, and the patients 
usually enjoy good health. Hence there is no special indication for 
internal medication. Hygienic rules should be observed in the man- 
agement of these cases, such as the daily administration of a cold 
sponge bath to the waist, together with careful attention to good nutri- 
tious diet, well-ventilated sleeping apartments, and especially to warm 
clothing. In all cases woolen underwear should be worn all the time 
both summer and winter, as we recognize a notable liability in these 
cases to taking cold. 

The galvanic current of electricity applied the same as heretofore 
prescribed for catarrh is very effective in these cases. After each 
seance apply some one of the antiseptics already prescribed, or a little 
of the oil lotion of pure linseed oil may be used, four ounces to one 
dram of the spirits of turpentine. This may be applied night and 
morning till well. The galvanic current may be applied every third 
day till relieved. 



CHAPTER LVIIL 

THE SKLN". 

The skin is a covering which invests the body completely, having 
three layers, namely, external, middle, and internal. It is a flexible 
membrane, and possesses both elasticity and extensibility. Upon its 
surface are numerous lines, or marks, of various forms and sizes, 
which are particularly well denned about the hands and feet. Large 
and coarse furrows occur about the joints and on the face. Numerous 
minute depressions also exist upon the surface and orifices of gland- 
ular ducts and of hair follicles. Hair, either fine or coarse, is found 
upon almost all regions of the body, and is more abundantly present 
on certain parts of the body than on others. To the touch the skin 
has a soft, smooth, somewhat unctuous feel. 

In color the skin varies exceedingly, being encountered of all 
shades, from whitish-pink to black, according to the race. It varies 
in thickness, depending upon the locality; it is thickest on the back, 
buttocks, palms, and soles, and thinnest on the eyelids. It is to be 
considered as an organ of touch, by means of which we obtain knowledge 
of the object with which we come in contact. It is extremely sensi- 
tive. This sensibility is found in different parts of the body, being 
most acute upon the ends of the fingers. 

The skin secretes both sebaceous matter and sweat, which serve 
to give it softness and suppleness. Certain regions give out the secre- 
tions in greater abundance than others. The scalp, for instance, is 
well provided with sebaceous glands, and the axillar with sweat glands. 
The function of perspiration is a most important one, and plays a con- 
spicuous part in the physical economy; when it occurs in an imper- 
ceptible manner, it is termed insensible; when in excess, sensible. 

The epidermis, or cuticle, is a membrane composed entirely of 
cells, which cover the corium in all its parts. It is a firm membrane, 
made up for the most part of connective tissue, together with elastic 
fibers, and contains blood-vessels, nerves, lymphatics, smooth muscles, 
hair glands, and flat cells. 

The sweat glands are convoluted bodies situated deep in the 
corium, or, as is more often the case, in the subcutaneous connective 
tissue- 
Primary lesions of the skin are many, and are of various sizes. 
They may be as small as a pin-head, or as large as the hand. In out- 
line they are usually roundish, but they may also be irregular in shape. 
In color and tint they vary exceedingly. They may, in fact, be of 
(720) 



i 



The Skin. 721 

any color; the more common colors, however, are reddish, yellowish, 
and brownish. They are the product of diverse causes, and conse- 
quently represent a number of pathological conditions. 

THE SEBACEOUS GLANDS SEBORBHOEA. 

Derivation. — The word is from the Latin sebum, suet. Sebor- 
rhea is a disease of the sebaceous glands, characterized by a quantita- 
tive or qualitative change in their secretions, which may then discharge 
upon the surface as an oily fluid, or in the f : rm of semi-solid fatty scales 
or plates, occasionally accompanied by dilatation of the orifice of the 
excretory ducts or glands. 

Etiology. — Seborrhea may be due to anemia or cachexia of the 
physiological functions of the sebaceous glands as a consequence of 
causes operating upon the surface of the body, derangements of the ali- 
mentary canal, the infectious granulomata (tuberculosis^ syphilii), 
exanthemata, inherited tendencies, or neglect of the rules of hygiene. 

Pathology. — Seborrhea is essentially a functional disorder, with- 
out primary structural changes of the sebaceous glands. 

Symptoms. — Seborrhea may be of the oily form, in which a fluid 
and oily secretion is poured out upon the surface ; or of the dry form, 
in which the secretion is furnished in the form of fatty plates, or 
scales. The disease may be general, involving the entire surface of 
the body. This is a rare and dangerous disorder, apparently allied to 
ichthyosis, in which, after the removal of the physiological vernix 
caseosa of the infant, the skin is seen to be deep red in color, with a 
tendency to become fissured and to furnish rapidly a horny incrusta- 
tion. Partial or local seborrhea usually affects the scalp, fur- 
nishing thus a sequel to the condition represented by the prenatal cap 
of vernix here accumulated. In this condition thin or friable greasy 
crusts of dirty yellowish or brownish hue cover a slightly macerated, 
often ill-smelling surface. These may persist for months, and 
lay the foundation for a future eczema of the region. Seborrhea 
of the face in children near the puberal epoch may form a greasy film 
of dirty, yellowish-green, somewhat adherent crusts over the forehead, 
cheeks, or nose, beneath which the skin is inactive, and macerated or 
inflamed. Often there are sensations of itching. Seborrhea of the 
umbilicus in children is remarkable for the fetid odor of the secre- 
tion furnished, and for the reddened ring of eczematous skin surround- 
ing the navel, which usually complicates the disorder. 

In the genital regions the tight prepuce of male children may 
imprison a fluid furnished by the sebaceous glands, producing local, 
and, by reflection, general symptoms of disorder. 

The same local symptoms may result from accumulation of the 
secretion about the labia and clitoris of young girls. 

Diagnosis. — Seborrhea is distinguished from eczema by the 
abundance and fatty character of the oily secretions and of its scale and 

46 



722 The Skin.. 

crusts, by the absence of the itching so characteristic of eczema, and 
by the absence of all inflammatory symptoms in the part affected. In 
psoriasis there are a more distinct definition, a more markedly circular 
outline, and more lustrous scales, the surface beneath them being red- 
dened, and exuding drops of blood when these scales are removed. 

Prognosis. — In children this is favorable. 

Treatment. — Internal treatment of this affection often requires at 
the outset an alterative cathartic, such as calomel or gray powder, to be 
repeated as desired. Iron and cod-liver oil are indicated in many 
cases. The diet is to be regulated with special care, excluding pastry, 
confectionery, hot bread, and oatmeal. The general surface of the 
body should be cleansed daily with a soap-and-water bath. Often the 
sulphide of calcium, administered in doses of one-tenth of a grain three 
or four times a day, is found beneficial. 

Locally all crusts should be softened by maceration in some fatty 
substance (as almond or olive-oil, vaseline, cold cream, or glycerine 
and water), then removed by washing in hot water and common toilet 
soap, green soap, or by the use of the alkaline spirit of soap of Hebra, 
sapo viridis two parts, alcohol one part, filtered and flavored with the 
tincture of lavender. After this a sulphur salve, one or two drams of 
precipitated sulphur to the ounce of salve-basis (lanoline or benzoin- 
ated sebum), may be applied. 

Another valuable lotion is acid sulphurous, four drams to four 
ounces of water. First wash the affected part with sulphur soap and 
warm water ; dry, and mop on the sulphur lotion for five minutes, and 
then apply the sulphur ointment. One ounce each of precipitated sul- 
phur, alcohol, glycerine, tincture of lavender, and rose-water may also 
be shaken up together, and used as a lotion, and applied before using 
the sulphur ointment. Carbolated, borated, and salicylated spirit 
lotion, one part of each to one hundred parts of cologne water, with 
■five parts of glycerine, is valuable for local applications to prevent the 
recurrence of these troubles. The spirit lotions are to be preferred in 
the local management of seborrhoea of the genital regions. 

COMEDO. 

Symptoms. — Flesh-worm, skin-grub. 

Definition. — Comedo is an accumulation of inspissated secretion 
in the efferent duct of a sebaceous gland, exhibited exterially as a yel- 
lowish or whitish pin-head-sized elevation, with a yellowish, bluish, or 
blackish central point. 

Etiology. — The causes of comedo are practically those of sebor 
rhoea, but the former is more often encountered in children. More 
commonly there is general torpor of the secreting glands of the skin, 
associated with either visceral inactivity, chloronsemia, malnutrition, or 
systemic poisoning. 



The Shin. 723 

Symptoms. — Comedones are present in almost every face, being 
conspicuous only when numerous. They are scanty and widely dis- 
tributed, or numerous and closely packed, bluish or blackish, pin-head- 
sized points, observed usually in greasy-looking skin. They are often 
associated with lesions of acne, occurring rather rarely on the scalp, 
much oftener inside the ears, on the face, neck, back, breast, and genital 
regions of children of both sexes, those especially near the puberal 
epoch. When expressed, a yellowish-white, worm-like, cylindrical 
mass, with a conspicuous blackish head, emerges from the slightly 
elevated, whitish rim of the follicle, from which circumstance is derived 
the common name of the malady, namely, the "blackhead," or "skin- 
worm." 

Diagnosis. — The comedo should not be confounded with the black- 
ish point produced by tar applied to the surface for medical purposes, 
or by alternate applications of mercury and sulphur, resulting in a 
deposit of the black sulphurate of mercury on the skin. 

Treatment. — The comedo is readily expressed out by the comedo 
extractor, after which the gland that has been constipated requires the 
treatment in general which is needful for the relief of seborrhoea. The 
affected part is to be washed in hot water, with or without the tincture 
of green soap and cologne water. After the bath, friction of the sur- 
face with a bit of white flannel on the finger is generally efficacious. 
A simple and elegant lotion for this purpose may be made of a half 
dram each of the tincture of benzoin and glycerine to four ounces of 
rose-water. A weak solution of corrosive sublimate, one-half grain 
to one grain to the ounce of the above solution, may also be applied 
for the same purpose. The author has found that the galvanic current 
of electricity will remove the constipation of the sebaceous glands, the 
positive pole applied over the constipated part on the face, the negative 
pole over the chest or between the shoulders over the spine, for seven 
minutes over each part of the surface affected. Give from ten to 
twenty milliamperes. A portion only of the affected part may be 
treated each day till all has been treated. Usually a dozen treatments 
are all that is necessary to effect a cure. Oxide of zinc, one and a half 
drams to one ounce of vaseline, is beneficial after using the galvanic 
current. The electric needle (galvanic) may be applied to each 
comedo, positive pole active, or make the needle positive. The zinc 
electrode (negative) is placed over the chest. The needle is applied to 
the center of the comedo and passed into the comedo; give live to ten 
milliamperes, from one to one and a half minute to each comedo. 
Treat a few comedones every day till all have had the electric needle 
applied ; then apply the oxide of zinc ointment. 

ACNE. 

Definition. — Acne is a chronic inflammatory affection of the 
sebaceous glands and periglandular tissues, in which variously- 
developed papulae or pustules, tubercles, or reddish blotches appear, 



■■HHH 



724 The Shin. 

usually upon the face or back, without producing marked subjective 
sensation. 

Etiology. — Acne in its simpler forms is usually encountered at 
about the puberal epoch. It occurs in both sexes. It is rarely seen 
in early life. It may be caused from gastro-intestinal derangements, 
anaemia, cachexia, accumulation of filth upon the surface of the body, 
also struma, tuberculosis, and ingested medicaments. 

Pathology. — The disease is usually caused by constipation of the 
sebaceous glands, and possibly results in the destruction of the gland 
and hair follicle. 

Symptoms. — In acne, reddish or violaceous, pin-head to pin-sized 
inflammatory papula?, or accumulated pustules and tubercles, few or 
numerous, often symmetrically disposed, appear upon the face,, brow, 
nose, cheek, chin, the neck, or the back, often commingled and inter- 
spersed with comedones and minute roundish abscesses. Seldom there 
is produced a sensation of pruritus or burning. Acnea punctata is 
characterized by the development of papulae, with a whitish or blackish 
comedo center. 

Diagnosis. — Syphilis is readily distinguished from acne by the 
localization of the lesion of the latter disease, and by the concomitant 
symptoms of the former malady. Syphilitic papulo-pustules of the 
face tend to cluster about the angles of the lips. The scalp, anus, and 
other regions of the body usually furnish evidence of any specific dis- 
order present. 

Variola is an acute exanthematous disorder with vesico-pustulae 
characteristically umbilicated. Impetigo has characteristic crusts. 
Acne is symptomatically not a disease of such type. Its crusts are 
always an insignificant part of the symptoms present. 

Treatment. — The internal treatment of acne is largely that indi- 
cated by the general condition of the patient, including the correcting 
of gastrointestinal disorders, the use of iron and cod-liver oil when 
indicated by anaemia and impaired nutrition. Occasionally glycerine 
may be given with advantage, in teaspoonful doses, twice daily. The 
bowels should be evacuated daily, and all injurious articles of food 
excluded from the dietary, as oatmeal, cracked wheat, and wheaten 
grits, the smaller seed-containing berries, hot bread and cakes, pastry, 
and confectionery. Fresh meats need not be excluded ; fruits and veg- 
etables are allowed. Poultry, fish, game, Tints, and very brown toasted 
bread may be eaten, also zwiebach. Regular intervals should be 
observed between meals, and no food should be taken except at meal- 
time. The entire body should be scrubbed daily from head to foot, in 
cool water and sulphur soap, in a warm room, in order to stimulate the 
secretory apparatus. After the bath, apply a sulphurous acid lotion, 
three or four drams of sulphurous acid in four ounces of water, and 
mop it on with a rag the same as in seborrhoea, then apply sulphur 
ointment. While shampooing, all pustules should be opened with a 
fine needle, thoroughly disinfected by dipping the needle in boiling 



The Skin. 725 

water with a little bicarbonate of soda in the water, and the purulent 
contents expressed. Locally the affected parts may be shampooed with 
the alkaline spirits of soap of Hebra with hot water; then apply the 
sulphurous acid, as above described, followed by anointing the affected 
part with sulphur ointment, rubbing into the skin finely-powdered 
sulphur once a day. This is best applied in the evening. 

A weak lotion of corrosive sublimate, from one-eighth to one-half 
of a grain to an ounce of spirit, may be employed with advantage. 
Van Harlingen employs one dram of the sulphur et of potassium and 
the sulphate of zinc one dram to four ounces of rose-water; this may 
be applied. 

Professor Una, of Hamburg, advises for external use before retir- 
ing to bed: — 

1^: Benzoinated zinc ointment 86 parts 

Precipitated sulphur 9 (or resorcin 10) parts 

Silicious earth 4 parts 

And use during the day another remedy : — 

1^: Resorcin 2 to 5 parts 

Glycerine 1 part 

Orange-flower water 20 parts 

Alcohol 80 parts 

Apply once or twice a day. 

MILIUM. 

Definition. — Milia are fine, isolated, pin-point to split-pea sized, 
having a pearly luster, covered with epidermis only, embedded within 
the skin. 

Symptoms. — They are often seen partly embedded in the skin 
over the temples, near the eyes, or about the cheek, nipples, and genital 
region of the young in both sexes. AEilia, when not treated, are usually 
in time thrown off from the surface of the skin with its natural exco- 
rium. The simplest treatment is by electrolysis, the milium, or the 
lesions, being punctured with a fine needle in an insulated needle-holder 
connected with the negative pole of from two to four cells of a galvanic 
battery, the positive pole being held in the hand of the patient, or placed 
over the chest wall. The sponge connected to the positive pole may be 
moistened with salt and warm water, titrate of silver (stick cautic) 
or nitric acid will remove them; this may be done by touching them 
with either of the remedies. 

ASTEATOSIS. 

Definition. — Asteatosis is characterized by a general or partial 
congenital absence or acquired diminution of the sebaceous secretions 
of the skin. 

Etiology. — The disease may be produced by malnutrition, 
cachexia, disorders of the nervous system, or other cutaneous affections. 

Pathology. — The skin, when examined, is found to be destitute 



726 The Shin. 

of its normal sebaceous secretions. There may be absence, atrophy, or 
temporary suspension of function merely, of the sebaceous gland. 

Symptoms. — In asteatosis the skin is dry, inelastic, less extensible 
than normal, and destitute of its usual unctuous feeling. The hairs are 
usually thinned and lusterless or absent. The nails also may be rugose 
and friable. The skin, in consequence of these changes, often becomes 
fissured and oozing, or scaly and crusted, in the regions involved. 

The slightest grade of this disorder is seen in some of the febrile 
diseases in childhood ; the gravest, in severe ichthyosis, lepra, and 
inherited syphilis complicated with marasmus. 

The congenital forms of this disorder, known as ichthyosis sebacea, 
are extreme manifestation of this condition, where children are brought 
into the world wholly unable to seize the nipple on account of the con- 
dition of the lips. 

Prognosis. — The prognosis is favorable in mild cases. 

Treatment. — The treatment is by external applications of oils, 
almond, cocoa, suet, palm-oil, vaseline. A mild climate is most suit- 
able for such cases. 

ANHIDROSIS. 

Synonyms. — Anidrosis, hypohidrosis. 

Definition. — Anidrosis is that morbid state of the skin in which 
there is a total absence of the sweat ordinarily effused upon the sur- 
face, or a diminution or arrest of sweating, as is indicated by a dry, 
harsh state of the skin. 

Treatment. — The faradic current of electricity should be used to 
stimulate the nerves. For alkaline baths use — 

li: Spiritus ammonite aromatici, 

Glycerinse, aa Jviii 

M. For a thirty-gallon bath ; use about twice a week. 

HYPERIDROSIS. 

Definition. — This is an effusion of the sweat secretion in relative 
excess, the fluid accumulating visibly upon the surface of the skin. 
It may be due to disorders of the nervous system, or to those of the 
circulatory system (the heart and blood-vessels). It may be due sim- 
ply to an elevated temperature, too much clothing, summer weather, 
unusual exertion, or ingested medicaments. 

Symptoms. — Localized hyperidrosis is limited to certain definite 
regions, such as the hands, feet, axilla, groins, temples, and genital 
regions. In generalized hyperidrosis, sweat is poured out in excess 
from all parts of the body. Children, and particularly infants, are 
especially liable to hyperidrosis (over-sweating) when kept in apart- 
ments with the temperature unduly elevated, or when they are too 
warmly clothed. 

Diagnosis.— The diagnosis is readily made by considering the 
moist and sweating condition of the skin. 



The Skin. 727 

Treatment. — In general, in hyperidrosis due to adynamic states, 
the ferruginous tonics, mineral acids, and quinine are indicated. 
Many children require special attention to the digestive function, 
proper dietary, and hygienic regulations of the bodily clothing, the 
covering of the crib or bed, and the temperature of the apartment in 
which they sleep or play. Children habitually overheated are in as 
much danger of disease as those the surface of whose body is habit- 
ually chilled. Bathing in tepid salt water, usually one-quarter of a 
pound of salt to a gallon of water, or with soap and water, usually 
sponging, and followed by brisk friction of the surface, is to be recom- 
mended. If there is any viscerai disease, cardiac cyanosis, or ansemia, 
salt is contraindicated. Sea-bathing surpasses in value in summer 
temperature. After the bath the sweating surface may be dusted with 
talc, boric acid, rice flour, or finely-powdered starch containing from 
three to five per cent of salicylic acid. Spirit lotion may also be 
employed, containing from one to two per cent of quinine, alum, tannic 
acid, or carbolic acid. If complicated with intertrigo, or any form of 
erythema, or eczema, when indicated, the unguentum diachyli albi of 
Hebra (see Eczema) or benzoated zinc salve may be used in the usual 
strength. 

Hebra's formula is as follows: — 

R: Olei olivse opt f^xv 

Pulv. lithargyri giii gvi 

Aquae q. s. 

Coque, flat unguent. 
The oil is to be mixed with a pint of water and heated, by means 
of a steam bath, to boiling, the finely-powdered litharge being sifted in 
and stirred continually; the boiling is to be kept up until the minute 
particles of litharge have disappeared. During the cooking process, 
a few ounces more of water are to be adde 1 from time to time, so that, 
when completed, water still remains in the vessel. The mixture is to 
be stirred until cool. The ointment is difficult to prepare, and requires 
skilful manipulation. When properly made, it should be a light yel- 
lowish color, and of the consistence of butter. To insure a good article, 
it is essential that the very best olive-oil and the finest litharge 
be employed. If unguentum diachylon is improperly made, it will 
not have the desired effect. 

]SText to diachylon ointment is Prof. McCall Anderson's, which 
is composed as follows: — 

H: Pulv. bismuth i oxide 3j 

Acidi oleici §j 

Cerae albas 3iij 

Vaselini Six 

Olei rosee 1\[ iij 

M. 
This, when well made, is elegant. It resembles butter in appear- 
ance and color, and when skilfully perfumed is a most agreeable prep- 
aration. 



CHAPTEK LIX. 
EKYTHEMA. 

Definition. — Erythema is a redness of the skin that temporarily 
fades upon pressure, and that appears in the form of diffused, circum- 
scribed, variously-sized lesions, usually without elevation above the 
skm. 

Symptoms. — The eruptions may appear in the form of patchy 
redness, or in diffuse streaks of different size and shapes. 

Etiology. — This form of erythema is brought about by the influ- 
ence of external irritation upon the skin, which, if left unchecked, 
may go on to true inflammation. Erythema is also caused from heat 
and cold. Erythema is caused, also, from pressure, rubbing, scratch- 
ing, and congestion arising from ill-fitting garments, instruments, etc., 
or the active disturbance set up by animal and vegetable poison. 

ERYTHEMA PERNIO ( CHILBLAINS ) . 

These are localized erythematous congestions that are very com- 
mon in weakly children, especially girls. 

The usual sites for the disorder are their feet and hands, but it 
may attack the nose, cheek, and ears. Chilblains begin in congested 
patches from the size of a dime up to that of a dollar, which may 
coalesce and form a continuous band. They itch, tingle, and burn 
most distressingly. After repeated attacks, the affected skin often 
becomes covered with vesicles, which often break down, leaving an 
excoriated surface that may ulcerate. 

Chilblains are liable to relapse each season, making their appear- 
ance in the fall, and not disappearing till warm weather. Children 
thus affected are not, as a rule, in good health. 

Treatment. — The treatment is both internal and local; must tone 
up the system. The most useful drug is iron in some form (Gude's 
or Wyeth's). Peptomangan of iron is the best preparation. Dose, 
from one to three teaspoonfuls after meals three times a day, to be 
taken in a wineglassful of water or milk. Eor strumous subjects, 
cod-liver oil and the hypophosphites are indicated, together with the 
lacto-phosphate of lime and (Fellows') syrup of hypophosphites, a 
teaspoonf ul to a half teaspoonful for an adult, according to age ; shake 
the bottle before using it ; taken after meals. Cold general sponging 
with brisk toweling is of great advantage. The child should be made 
to wear stout, easy-fitting boots and woolen stockings. The patient 

(728) 



Erythema. 729 

should sleep in a moderately warm room, and knitted bed-slippers 
should be kept on in bed during the night. For immediate relief for 
chilblains, very hot water application gives the most comfort. 

Calomine and zinc lotion is very agreeable. 

3.: Zinci oxidi 3ss 

Pulv. calami use, prsep Biv 

Glycerinse 5J 

Aquae calcis 3vii 

M. et ft. lotio. 

Use several times a day. 

Painting the parts freely and frequently (night and morning) 
with tincture of iodine gives great relief. 

Belladonna liniment, painted upon the part, allowing it to dry, 
relieves itching. 

Tincture of cantharides and soap liniment (1 :6) is very beneficial, 
or equal parts of turpentine, spirits of camphor, and olive-oil will 
relieve itching. If vesicles or ulcers form, dress the parts antisep- 
tically. 

One of the most soothing remedies is spirits of turpentine two 
drams, zinci oxidi two drams, linseed oil two ounces. Cleanse the 
parts with warm water with a few drops of carbolic acid in the water, 
dry the parts, apply the turpentine and zinc lotion above prescribed. 

When a chilblain is only a congested spot, it should be washed 
twice a day in cold salt water, and rubbed dry with flannel. Paint 
with tincture of iodine. The patient with chilblains must take regular 
outdoor exercise, and must not sit near a hot fire. 

ERYTHEMA INTERTRIGO. 

This form of erythema is always first a simple hyperemia of the 
skin, which occurs on parts of the body exposed to friction from cloth- 
ing or from two surfaces being in contact, as underneath the armpit 
(axilla), in the creases of the legs and neck, the gluteal furrows, the 
inner surfaces of the thighs, and the flexures of joints, especially in 
fat babies. 

Intertrigo, or chafing, in infants may appear quite suddenly, and 
under proper management may last but a few hours ; but if neglected 
or improperly treated, it may persist for weeks. It most frequently 
occurs in hot weather, although in infants it may be observed at all 
times of the year. There are relapses expected. The eruptions on 
the buttock by the irritation of faeces and urine are very common, espe- 
cially in syphilitic children or infants. 

Treatment. — Cleanliness is to be secured by washing with pure 
soft water and pure white castile soap, and frequent changing of the 
diapers. The infant must not lie with wet or soiled diapers on, as they 
will increase the chafing and inflammation. 

The diapers should be washed with castile soap and thoroughly 
rinsed. The author witnessed the death of an infant (a girl), which 



730 Erythema. 

was due to an acute inflammation of the buttocks and genitals, caused 
by the use of diapers washed with lye soap and not properly rinsed. 

For immediate removal of, and protection against, irritating dis- 
charges, a simple dusting powder may be used : — 

ft: Zinci oxidi 3ij 

Pulv. sem. lycopodii , . . . 3vi 

M. et ft. puis. Keep the parts dusted. 
After the disease has become established, lint should be kept 
between the folds, in small pieces, to keep the parts separate. The 
following lotion is useful: — 

* ft: Argentum nitras , gr. viii 

Aquae distil gij 

M. et ft. lotio. 
Cleanse the parts with warm water, apply the lotion with a soft 
rag or mop it on gently, then apply oxide of zinc ointment plentifully. 

Zinci oxidi 3jss 

Vaseline 3j 

M. et ft. unguentum. 
Keep the affected parts separated with a bit of lint. 
Duhring advises Lassar's paste: — 

ft: Acidi salicylici gr. x 

Zinci oxidi 

Amylis, aa gij 

Vaseline 3iv 

M. et ft. unguentum. 
Keep the affected parts anointed by spreading thinly over the 
surface. 

SYMPTOMATIC ERYTHEMA. 

Evanescent congestions of the skin during dentition are quite 
common in children who are teething or suffering from some slight 
derangements of the alimentary canal. These rashes generally assume 
the roseolar form, and are accompanied by a slight elevation of tem- 
perature and perhaps some redness, without swelling of the palate and 
fauces. It is said to be most common over the sacral regions and but- 
tocks. It usually disappears in a few hours to a few days without 
desquamation. 

Treatment. — A mild laxative is all that is needed ; also nutritious^ 
and easily-digested food. 

FURUNCEES (BOILS). 

Definition. — A furuncle is an acute, circumscribed, phlegmonous 
inflammation occurring around a skin gland or follicle, and terminat- 
ing in suppuration and the expulsion of a central slough, or core. 



Erythema. 731 

Etiology. — When boils occur singly, it will be found that they 
have been caused by some local irritation, the pressure of ill-fitting 
instruments, prolonged lying down (or decubitus), or the irritation of 
the skin by rough garments. It is a well-recognized matter of experi- 
ence that furuncles occur in connection with a variety of constitutional 
states of depressing character, as in diabetes, variola, measles, scarlatina, 
etc. Von Rittersham states that after exfoliative derminitis of infants, 
furuncles often follow eczema, and are very annoying and often pro- 
tracted. 

In hot summers, children are very subject to prickly heat, which 
is often accompanied by crops of furuncles. A most painful and per- 
sistent furunculosis is often seen in connection with chronic intestinal 
catarrhs of children. 

Diagnosis. — A boil may be distinguished from a carbuncle by its 
smaller size, its more pointed shape, and its single point of suppura- 
tion, whereas a carbuncle is generally solitary, much flatter, and larger 
than a boil, has an indurated border, and, in addition to its several 
openings, the overlying skin is completely destroyed. 

Prognosis. — The prognosis of boils is usually good. 

Treatment. — The first duty is to put the patient in the best pos- 
sible condition of health ; if there is sewer gas or arsenical wall paper 
they should be removed and remedied. The dyspeptic, the ansemic, 
and the strumous should each receive appropriate treatment. Very 
often change of scene and air is beneficial. 

Yeast is an old-fa shionecl "cure." An adult may take a half wine- 
glassful night and morning. Sulphide of calcium, half-grain doses 
every four hours for adults, for children may be administered in doses 
one-tenth to one-fortieth of a grain four times a day. 

Syrup of hypophosphites (Fellows'), for adults, teaspoonful after 
meals three times a day, to be taken in a wineglassf ul of water. 

Cod-liver oil emulsion is beneficial in strumous children. 

L. Heitzmann strongly recommends an eight per cent of salicylic 
acid plaster or salve. 

Tincture of iodine is often beneficial ; it must be put on in suc- 
cessive layers, and allowed to encroach a little on the healthy skin. 
He also advises that all other lesions of the cutaneous surface be simi- 
larly treated, to prevent their development into furuncles. 

Lowenberk uses a saturated solution of boracic acid. Verneuil 
recommends a two per cent solution of phenic-acid spray. The follow- 
ing application is recommended by Halle and Jamieson ■ — 

]£: Tinct iodine 3j 

Acid tannic 3ss 

Pulv. acacise 3ss 

Mix. Keep the boils painted with it. 
Hardaway's plan is to apply to the furuncle a piece of Una's plas- 
ter. Carbolic acid and mercury plaster on mull, cut so as to cover the 



32 Erythema. 



lesion and project a little beyond. On no account should poultices be 
made to encourage suppuration. 

After using Una's plaster of a few hours' application, it will gener- 
ally be found that the boil has burst, or that the slightest prick with 
a knife or needle will cause the pus to flow out. A small hole may 
be cut fn the center of the plaster corresponding to the apex of the 
boil. Squeezing and other manipulations should be avoided. After 
the furuncle has burst, the cavity should be treated antiseptically. 
Wash the cavity with peroxide of hydrogen with equal parts of warm 
water; apply with a dropper, then use carbolized oil. Olive-oil one 
ounce, carbolic acid three to five drops, or turpentine and linseed oil 
may be used. Turpentine one dram, to • ne ounce of linseed oil, is 
very beneficial. If the turpentine should burn, add a little more lin- 
seed oil ; apply with a dropper, and put on absorbent lint. Dr. H. 1ST. 
Spencer says he uses an application of an ointment composed of 
extract of arnica, extract of belladonna, and morphine to alleviate 
pain, and to prevent the occurrence of others ; he also uses compres- 
sion. He adds that the knife should not be employed ; and poultic- 
ing, syringing, and the instillation of warm water or drops of any 
character, are to be condemned, entering largely, as they do, as fac- 
tors in producing ear trouble. Absorbent cotton is the best thing for 
absorption that can be used. Pressure that is brought to bear uni- 
formly upon all the walls of the canal prevents the development of 
furuncles, by its influence upon the circulation, at the same time that 
it operates upon those which have formed to promote resolution or 
the culmination of their discharge. 

The After Treatment. — This should look to their local cause, and 
remove it. If any inflammatory trouble exists, whether of the 
meatus or tympanic cavity, use Dr. H. N". Spencer's unguentum : — 

IJ: Ext. arnicas 3jss 

Morphias sulphate gr. viii 

Ext. belladonnas gr. viii 

Vasilini 

Lanoline ad ^ss 

M. et ft. unguentum. 
Sig. : Keep the ointment applied and use compression. 

PHLEGMON (iJECEKS). 

Definition. — Phlegmon is an inflamamtion of the cellular or areo- 
lar tissue. This tissue is present in the human body from head to 
foot. 

It may be acute, diffused, or circumscribed, chronic, or malignant. 

Etiology. — It is described as occurring idiopathically, but H. 
Tuholske, M. D., believes it to be mostly secondary to an existing 
neighboring inflammatory or necrotic process, or of trans-mutico sep- 
tic origin. It is often associated with phlebitis or lymphangitis, of 
which at one time it may be the cause, and at another the effect; 



Erythema. 733 

or with erysipelas, from which it differs in this, in phlegmon the 
cellular tissue is primarily inflamed, while in phlegmonous erysipelas 
the inflammation of the skin and cellular tissue results from the same 
cause, or the skin is affected first, and the cellular tissue secondarily. 
It may be of puerperal origin. The pathological process is every- 
where the same. 

Symptoms of Acute Phlegmon. — After the first day or two, 
when the patient complains of a tender, stiff, tingh'ng feeling, the 
swollen part becomes shining and painful, frequently very much 
so; the swelling is diffuse, uniform, slightly raised above the surface, 
and without a well-defined border. Although the skin does not par- 
ticipate primarily, or at first, it presents a reddish, erythematous 
appearance, which, as the disease progresses, becomes brawny, dusky, 
and cedematous. The swelling, which at first had been tough and 
inelastic, loses in firmness, becomes doughy and finally soft, and if not 
too deeply situated, fluctuation becomes distinct. The suppurating 
process will now spread in the direction of the least resistance, follow- 
ing the sheaths of tendons which it involves, and along the veins 
and fascias toward the integument, until this, in one or more places, 
eventually gives way and allows the discharge of pus and necrotic 
debris. 

As a rule, if nature has her way, this takes place only after 
pieces of fascia have been destroyed, tendons have become necrotic, 
and the destructive process has spread far beyond its original limits. 
Then the slough gradually separates, a reparative process assisting in 
their removal; granulations form, and the patient recovers, some 
shortened tendon, contracted fascia, or fistulous tract remaining as 
lasting evidence of the destructive tendency of the disease. The 
patient suffers with fever and chills at the time of the pus formation. 
In any case thrombosis of involved veins may lead to infarction in the 
lung, or a thrombus becoming septic to suppurative embolic processes. 
Treatment. — General treatment is valuable; promptly meet every 
indication as it presents itself; but local treatment is paramount. 

Watch the patient's temperature and secretions, and administer, 
if the bowels are constipated, a laxative, also quinine and nutritious 
food. 

The remedies to be applied locally are mercurial inunction with 
absolute rest of the part, and elastic bandage. H. Tuholske recom- 
mends absorbent cotton wrung out of a two-per-cent solution of carbolic 
acid, enough to envelop the affected part and cover beyond it ; cover the 
cotton with oil silk, and retain it by a bandage snugly applied. This 
should be changed two or three times daily. A flaxseed and laudanum 
poultice may accomplish the object. Whenever the presence of pus 
can be located in children, incision, deeply and multiple rather than 
extensive, should be promptly made, and followed by thorough infec- 
tion, complete drainage, and antiseptic dressing. If the presence of 
pus can not be demonstrated by the sign of fluctuation, because of its 



734 Erythema. > 

being too deeply situated, but is inferred by the oedema and pitting 
and intense localized tenderness, incision is demanded. 
The furuncle is a typical circumscribed phlegmon. 

ULCERS. 

Definition. — An ulcer is solution of continuity in the surface of 
the skin or mucous membrane, deeper than its epithelial covering, and 
maintained by causes local or general. In all cases it results from the 
molecular death of a portion of the skin or mucous membrane itself, 
a sequel to a suppurative inflammation, and disposed less to the forma- 
tion of granulation tissue than to a progressive destruction along its 
periphery. 

Etiology. — The action of the pus cocci is the same as in an abscess. 
A broken abscess becomes an ulcer, and an ulcer is a half section of an 
abscess. An abscess arises from molecular death in the tissues; an 
ulcer, from molecular death of a free surface. 

Classification. — Ulcers are classified into groups according to the 
condition of the ulcer and the constitutional state of the patient. All 
ulcers, whatever their origin, are either acute or chronic, and such 
conditions as great pain, hemorrhage, oedema, exuberant granulations, 
phagedena, sloughing, struma, gout, syphilis, scurvy, etc., are to be 
looked upon as complications. 

The leg is so common a site for ulcers as to warrant special 
description. Acute ulcer of the leg may follow an acute inflammation, 
and may be acute from the start, or may be first chronic and become 
acute. It is characterized by rapid progress and intense inflamma- 
tion. In shape these ulcers are usually oval. 

The bottom of an acute ulcer is covered with a mass of gray, 
aplastic lymph, or it may have upon it large greenish sloughs. The 
edges are thin and undermined. The discharge is very profuse and 
ichorous, excoriating the surrounding parts. The adjacent surface is 
inflamed and oeclematous. There is a burning pain. When the ulcer 
spreads with great rapidity and becomes deeper as well as larger in 
surface area, it is called "phagedenic." If sloughs form, this indi- 
cates that tissue death is going on so rapidly that the dead portion has 
not time to break down and be cast off. Constitutionally there is gastro- 
intestinal derangement, but rarely fever. 

Treatment. — De Costa recommends giving a dose of blue mass, 
or calomel, followed in eight or ten hours by a saline laxative (two 
drams each of Kochelle and Epsom salts.) Order light diet. Do not 
give stimulants except in diphtheritic ulcer. Administer opium if the 
pain is severe. 

Use a spray of peroxide of hydrogen; remove the sloughs with 
scissors and forceps, and after their removal wash the ulcer with cor- 
rosive sublimate solution, one to five thousand. If the sloughs can 
not be removed, use the antiseptic poultice, and have at hand a bottle 



Erythema. 735 

of linseed oil with, carbolic acid in it, — four ounces of linseed oil to 
thirty drops of carbolic acid, — and spread a little of this over the poul- 
tice before applying. 

After asepticizing, local bleeding is of great value. De Costa 
recommends tying a fillet below the knee ; then make multiple punctures, 
and let the patient sit with his leg in tepid water until a few ounces of 
blood have been lost (from five to ten ounces) ; untie the fillet, dress 
with antiseptic poultices, keeping the leg elevated. In two days paint 
around the ulcer with equal parts of tincture of iodine and alcohol, and 
repeat this treatment every day, dressing the ulcer with antiseptic 
gauze (either salicylated or treated with iodoform). After painting 
the ulcer, apply a roller bandage ; flannel is to be preferred. 

If the discharge is offensive, use gr. iij of chloral to every Sj of lead 
In any case thrombosis of involved veins may lead to infaselLon in the 
water. 

A twenty-five per cent ointment of ichthyol is highly valuable. 
If sloughs continue to forni, touch with a pure solution of carbolic 
acid, and re-apply antiseptic poultices. If the ulcer continues to 
spread, clean it up with peroxide of hydrogen, dry with absorbent 
cotton, toiich with nitrate of mercury solution (1:8), and apply a 
poultice. Do this every day until the ulcer ceases to spread, and 
granulations begin to form. 

If the ulcer is covered with a great mass of aplastic lymph, touch 
it daily with a solution of nitrate of silver (gr. xxiv to %i to gij of 
water), and dress with iodoform gauze. Give internally tonics, — 
elixir iron, quinine, and strychnia, or Fellow's syrup of hypophosphites 
after meals, a teaspoonful dose in a wine-glass of water. If iron alone 
is needed, Glide's or Wyeth's peptomangan of iron is very useful. A 
little tincture of nux vomica may be added to the mangan of iron, ojss 
to .?xii. The dose of the peptomangan is from one to two or three tea- 
spoonfuls, according to the condition of the patient. Stimulants are 
useful, and plenty of good food is needed. In all cases where granu- 
lations form, the leg should be dressed with dry dressing. If granu- 
lation is slow, touch every day with a solution of silver nitrate (gr. x to 
51 of water), or with a stimulating ointment (resin cerate or 5j of 
unguentum hydrarg. nitratis to Sviii of unguentum petrolii), or with 
an ointment of copper sulphate (gr. ii to iii of unguentum petrolii). 
The author has found linseed oil and turpentine to be very useful in 
the following proportions: — 

9: Linseed oil giv to vi 

Turpentine spt 5j to ^ij 

Oleo Harlum 3j to iss 

Mix. 

Wash the ulcer with warm water, to which a few drops of carbolic 
acid have been added ; dry with a soft rag or absorbent cotton, anoint 
with the oil, lay on iodoform gauze, apply more of the oil, lay on 
absorbent cotton (a small bit) ; apply oil silk over this, and then a 



736 Erythema. 

roller bandage. I have seen old ulcers heal very readily under this 
treatment. 

The leg should be kept elevated until pretty well healed, and it 
must be kept snugly bandaged until well. If there is much aplastic 
lymph, cleanse it with perchloride of hydrogen, and dress as above 
advised. 

In treating chronic ulcers, give a saline laxative every day, 
Epsom salts one dram, Kochelle salts one to half an ounce, taken in a 
half tumbler of water every day. 

Chronic ulcer may be chronic from the start, or it may be acute. 
More usually it is found as a solitary ulcer two inches above the inter- 
nal malleolus. Syphilitic ulcers occur in groups, are often chronic, 
and are frequent upon the front of the knee. A chronic ulcer is cir- 
cular or oval, and is surrounded by congested, discolored, and indurated 
skin, and there is often eczema or a brown pigmentation of the neigh- 
boring skin. The patient must take tonics, eat nourishing food, and 
have plenty of rest. 

Dr. De Costa draws blood by shallow scarification of the bottom 
of the ulcer, and through the skin into the deep fascia. After the 
incision is made, dress antiseptically for two days, keep the part ele- 
vated, permitting contraction, allowing granulation to sprout in them, 
which aids in the absorption of the exudate. In two days after scari- 
fication or incision, the ulcer is scraped with a curette until sound tis- 
sue is reached; then make radiating incisions through its edge. Use 
antiseptic poultices for two more days; then paint around the ulcer 
with tincture of iodine and alcohol (1 to 3), and dress the leg with 
laudanum and hot lead water. When healing begins, treat it the same 
as for healing acute ulcer. 

Complications. — Remove by scissors and forceps any useless tis- 
sue ; take out dead bone ; slit sinuses ; trim overhanging edges. Treat 
eczema by attention to the bowels and stomach, and locally by washing 
with Johnson's ethereal soap and by the use of powdered oxide of zinc 
or borated talcum, the leg being wrapped in cotton. 

Avoid ordinary soap, grease, and ointment; those used must be 
antiseptic. Varicose veins demand either ligation in several points, 
excision, or the continued use of a flannel roller bandage or a Martin 
rubber bandage, or a silk rubber stocking. Inflammation is met by 
rest, elevation, and painting the neighboring parts with dilute iodine, — 
iodine and glycerine equal parts, — and by the use of a hot solution of 
lead water and laudanum. Calloused edges may be cut away; ordinary 
thick edges can be strapped. Use adhesive plaster in strapping, and 
do not completely encircle the limb. When the parts are adherent, 
completely or partly surrounding the sore, the deep fascia may be cut 
through to favor granulations. If the bottom of the ulcer is foul, dry 
it, and touch it with a solid stick of nitrate of silver ; repeat this every 
third day, and dress with an antiseptic poultice until granulations 
appear. Superfluous granulation must be touched with nitrate of sil- 



Erythema. 737 

ver. When a woman having an ulcer must go out, use a firmly-applied 
roller, or, better still, a Martin bandage. The bandage may be used as 
follows : — 

Before getting out of bed, spray the sore with peroxide of hydro- 
gen by means of an atomizer, dry off the froth with absorbent cotton, 
wash the leg with castile soap and water, dry it, and put on the band- 
age, all of which should be done before putting a foot to the floor. At 
night after getting in bed, take off the bandage and wash with soap 
and water, and dry it, and again cleanse the leg and ulcer. If these 
rules are not strictly observed, the Martin bandage will produce pain, 
suppuration, and eczema of the leg. 

Ulcers in Any Region. — The fungus, or exuberant ulcer, is found 
especially common in burns and other injuries when cicatricial con- 
traction causes venous obstruction. These granulations bleed when 
touched. Burn them off with a stick of nitrate of silver, and strap 
or use the rubber bandage. Irritable or painful ulcers are very sensi- 
tive; this is due to the exposed nerve filament. They are especially 
found near the ankle, over the tibia, in the anus, or in the matrix of 
the nail (in ingrowing nail). Curette the ulcer, and touch it with 
pure carbolic acid, or with the solid stick of silver nitrate. Chloral, 
gr. xx to one ounce of water, applied on lint, allays the pain. 

Phagedaenic Ulcer. — The phagedenic ulcer, which means the pro- 
found microbic infection of tissues debilitated by local or constitutional 
disease, is commonly venereal. This ulcer has no granulations, and is 
covered with sloughs ; its edges are thin and undermined, and it spreads 
rapidly in all directions, and requires the use of strong caustics, fol- 
lowed by iodoform dressing. Internally use tonics and stimulants. 

Rodent, or Jacob's Ulcer. — This is a superficial epithelioma, 
developing from sebaceous glands, sweat glands, or hair follicles. 

Bed-sores are due to pressure upon an area of feeble circulation. 
The perforating ulcer commonly affects the metatarso-phalangeal joint, 
or the pulp, of the great toe about a corn. The part about the corn 
inflames, and pus forms, which runs into the bone; a sinus evacuates 
the pus by the side of the corn. Treatment of perforating ulcer con- 
sists, according to Treves, in going to bed and poulticing. Every time 
the poultice is removed, the raised epithelium around the ulcer is cut 
away, and then the poultice is re-applied. In about two weeks an 
ulcer remains surrounded by a healthy tissue. 

Treves treats this sore with glycerine made to a creamy consistency 
with salicylic acid; to each ounce of this mixture add ten minims 
(7tlx) of carbolic acid. He directs the patient to wear, during the 
rest of her life, some kind of form of bunion plaster, to keep off 
pressure. If in a perforating ulcer the bone is diseased, it must be 
removed. 

Fistula. — A fistula is an abnormal communication between the 
surface and an internal part of the body, or between two natural 

47 



738 Erythema. 

cavities or canals. The first form is seen in a rectal or a biliary fistula, 
and the second is seen in a vesico-vaginal fistula. 

Fistulas may result from congenital defects, from sloughing, 
traumatism, and suppuration. Fistulas are named from their situa- 
tion and communication. 

A sinus is a tortuous tract opening, usually, upon a free surface, 
and leading down into the cavity of an imperfectly-healed abscess. A 
sinus may be an unhealed portion of a wound. Many sinuses may be 
due to pus burrowing subcutaneously. A sinus fails to heal because 
of the presence of some fluid (as saliva, urine, or bile) ; because of the 
existence of some foreign body, as dead bone, a bit of wood, a bullet, a 
septic ligature, etc., or because of rigidity of the sinus walls, which 
rigidity will not permit collapse. Sinuses may be due to want of rest 
and to general ill health. 

DECUBITUS (BED-SORE). 

A bed-sore is the result of local failure of nutrition in a person 
whose tissues are in a state of low vitality from disease or from injury. 
Such sores are due to pressure, aided by the presence of urine and 
fseces, sweat, wrinkling of sheets, or to the dropping of crumbs in the 
bed. The pressure interferes with the blood supply, the weakened tis- 
sues inflame, vesiculation occurs, sloughs form, and an ugly ulcer is 
exposed. 

Treatment. — The "ounce of prevention'' is here invaluable. From 
time to time alter the position of the patient, if possible; keep the 
patient clean, maintain the blood distribution of the skin by frequent 
rubbing with alcohol and a towel, and keep the sheet clean and smooth. 
When congestion appears, at once use an air-cushion, and change the 
position of the patient. Let the affected part rest on a downy pillow ; 
it will give great comfort. Not only protect, but harden the skin ; 
wash the part twice daily, and apply spirits of camphor, or glycerole 
of tannin, or rub with salt and whisky (3ii to qj), or apply a mix- 
ture of ,f ss of powdered alum, fL?ii of tincture of camphor, and the 
whites of four eggs; apply two or three times a day; or apply 1 annate 
of lead; or equal parts of oil of copaiba and castor-oil; or paint on 
a protective coat of flexible collodion. 

When the skin seems on the verge of breaking, paint it with a 
solution of nitrate of silver (gr. xx to Ei of water). When the skin 
breaks, a good plan of treatment is to touch once a day with nitrate 
of silver solution (gr. x to the ounce of water), and cover with zinc 
ichthyol gelatin. We can wash the sores daily with 1 :2000 cor- 
rosive sublimate solution, dust with iodoform, cover with lint, and 
spread with oxide of zinc ointment. When sloughs form, cut them 
off with scissors after cleansing the part. Slit up sinuses, and use' 
antiseptic poultices ; in obstinate cases use the continuous hot brth, or 
the intermittent ice poultice. When the slough separates, dress anti- 
septically with carbolic acid in warm water, or with corrosive subli- 
mate solution as above described, or equal parts of resin cerate and 



Erythema. 739 

balsam of Peru may be used. If healing is slow, touch occasionally 
with silver solution, gr. x to Sj of water. The patient should be stim- 
ulated, well nourished, and should have good sleep. 

URTICARIA. 

Synonyms. — Nettle-rash, hives. 

Definition. — Uticaria is an inflammatory, non-contagious affec- 
tion of the skin, characterized by the more or less sudden development 
of wheals, associated with burning, tingling, and itching sensations. 

History. — Urticaria may occur as a sudden outburst, almost 
furious in its character, involving much of the surface and causing 
great suffering ; or it may appear more slowly, with the development of 
a few wheals, which may come and go even for a period of weeks and 
months. 

Etiology. — The etiology of urticaria is frequently very obscure ; 
while in certain cases, especially of the more acute form, it will be 
caused by irritating food, such as fish, strawberries, pineapple, etc., or 
by an acute attack of indigestion, or by certain drugs, especially 
quinine, in a large proportion of cases, it seems impossible to train 1 
the eruption to any special cause, and the most rigorous attention to 
diet will fail to produce any beneficial effect upon the disease. 

It is recognized, however, that in the main urticaria depends upon 
disorders of the digestive system, and in children it is not infrequently 
caused by the presence of intestinal worms. In certain cases there will 
be a marked periodicity in the eruption, and it will be found that 
malaria is the cause of it, and this can be checked by quinine. 

Pathology. — The immediate causation of the wheals of urticaria 
lies, in all probability, in vasomotor disturbances, which may have 
either a central, a peripheral, or reflex origin. The essential element 
in the production of the wheals is a spasm of a localized tuft of blood- 
vessels, followed by relaxation and the consequent effusion of fluid, 
producing a localized oedema in the skin. The sensation of itching, 
burning, and tingling are the natural result of the compression of the 
sensitive nerves by the exudate, or may be in part due to the same 
direct or reflex irritation which excited the vascular spasms. 

Several varieties of urticaria are described, and may be observed. 
We have: — 

Urticaria Communis. — This represents the eruption when the 
wheals, of whatever size or shape, remain such during their course. 

Urticaria Papuloso. — This variety is more commonly seen in chil- 
dren than in adults. In it there is, in addition to the wheals, which 
are generally about half an inch in diameter, a small papule developed 
in the center, which remains after the subsidence of the wheal, and, 
consisting of organized lymphs, may persist for a day or two. 

Urticaria Tuherosa.- — Occasionally this form may take on great 
size, some of the elevations being raised up to the. size of half a large 
walnut : but this rarelv occurs in children. 



740 Erythema. v 

Urticaria Oedematosa, — When lesions are developed in situations 
where the tissue is lax, as about the face, there may be a very consider- 
able amount of oedema, so that even the eyes may be closed, and the 
tongue or lips may be greatly swollen; these are, however, generally 
very transitory, and do not call for active interference. 

Urticaria Bullosa. — In rare instances, vesicles and blebs of greater 
or less size, are formed in connection with urticarial wheals. 

Diagnosis. — There is very little difficulty in diagnosing most 
cases of urticaria. The sudden appearance of the wheals, the peculiar 
burning and itching, and the irregular and more or less general dis- 
tribution of the eruption, are generally sufficient to make the diagnosis. 

Prognosis. — The prognosis of urticaria will differ greatly in dif- 
ferent cases. Acute outbreaks caused by indigestion or irritating food 
commonly cease in a few days under appropriate treatment and proper 
regulation of the life of the patient. But if neglected, the acute may 
run into the chronic state, which may prove rebellious. 

The papular urticaria in children will sometimes persist for weeks 
or even months, in spite of the best treatment ; but in the end the dis- 
ease is curable in most cases. 

Treatment. — Simple acute cases of urticaria may require little 
more than evacuation of the stomach, if offending matter is still there. 
A moderate purge of castor-oil or rhubarb and soda, and a little cream 
of tartar water drank rather freely, will do good. But in chronic 
cases the utmost care in regard to diet, together with internal and 
external treatment, will often be required. In some instances, careful 
attention to diet will fail to make any impression on the case. During 
the entire course of the disease the diet should be plain, simple, and 
unstimulating, though abundantly nutritious, and a very moderate 
proportion of sugar should be used. Alkalies are necessary in most 
cases. 

Rhubarb and soda mixture with peppermint water is made as 
follows : — 

li: Sodii phospliatis 3vi 

Rhubarb Z vi 

Aqua? mentli pip ^vii 

M. et sig. : For an adult, a dessertspoonful after meals is sufficient 
to secure a moderately free action of the bowels daily. Acetate of 
potash, one to two drams, may be added to the above mixture. The 
dose for a child under twelve years of age is from half a teaspoonful 
to a teaspoonful. 

Alternating with this, iron and arsenic or cod-liver oil will gen- 
erally be found sufficient for the cure. The hypophosphites are also 
frequently called for, and quinine, for children, may sometimes be 
given in free doses with the best of effect. 

Ijc: Syr. of hypophosphites (Fellows') %iv 

Essence of pepsin (Fairchild's) . . . |iv 



Erythema. 741 

M. sig. : For children under twelve years, give from half a tea- 
spoonful to a teaspoonful, according to age, to be taken in a wine-glass 
of water. For an adult, two teaspoonfuls after meals in a wine-glass 
of water. 

Locally the free use of the following lotion will generally be found 
to give relief. At the onset of an acute attack of urticaria, manifested 
by tingling, burning, and itching, the rash making a bold appearance 
upon the surface of the skin, rub dampened soda bicarbonate (baking 
soda) upon the affected parts for a few minutes, and then take a hot 
bath for about ten minutes, with plenty of soda in the bath water ; it 
will give quick relief. Take a quick laxative to move the bowels freely. 
A tablespoonful of the flour of sulphur, with molasses, is very useful, 
and almost every family has these on hand, or a dose of Epsom salts is 
good. After the hot soda bath, the patient must be kept in a warm 
room for several hours. 

The hot soda water may be kept applied until all the eruption 
has disappeared, by mopping on hot soda water, and keeping the parts 
covered until relieved. The following is found to be very beneficial 
in giving quick relief : — 

\y. Pulv. calamine prsep. . . . 3j 

Zinci oxidi 3ij 

Acidi carbolici 3ss 

Glycerini 3iij 

Aquae calcis 3iv 

Auqse rosse, ad 3iv 

Mix. 
This lotion may be applied several times daily, or when desired 
for relief of the itching, day or night. In some instances a powder 
gives the most relief, and the following, well rubbed on the skin with 
the palm of the hand, forms a very agreeable application. After the 
soda bath, the surface of the body should be dried and thoroughly 
anointed with carbolated carmolirie: — 

5' Unguentum petrolii gij 

Acid carbolici 5ss 

M. et ft. unguentum. 
Keep the affected parts anointed. 

HERPES (ZOSTER). 

Synonyms. — Zona, shingles. 

Definition. — Shingles is an acute inflammatory eruption, exhibit- 
ing groups of vesicles upon an inflamed and very sensitive surface cor- 
responding to a definite nerve tract, and accompanied by more or less 
neuralgic suffering. 

History. — Shingles usually comes on with neuralgic pain, more 
especially from acute indigestion ; but it may come on without any dis- 
turbance of the digestion. The pain may be very acute in the part 
about to be affected ; sometimes there mav be a little fever. 



742 Erythema. 

Etiology. — Atmospheric changes, cold draughts, and exposure to 
wet, can cause the nerve inflammation associated with the eruption. 
Zoster is quite common among children. 

Pathology. — The skin lesion in zoster, or shingles, is the direct 
result of irritation of the nerves distributed to the affected skin. This 
irritation may exist in any part of the course of the nerve, but is most 
commonly found in the spinal ganglia, and a number of autopsies have 
demonstrated intestinal neuritis of the posterior or sensory ganglion, 
as was first shown by Bareusprung; but later researches have also 
demonstrated this to be healthy in some cases, while neuritis existed 
in other portions of the nerve. Cases are also reported where there 
was hemorrhage into the Gasserian ganglion, also into the cauda 
equina, in a case of aural herpes ; also where there was disease or 
injury of the spinal cord, and many other conditions inducing nerve 
irritation and inflammation. 

Symptomatology. — The eruption of zoster is developed along the 
line of some distinct nerve tract or area, most commonly about the 
trunk, and with the rarest exceptions is always confined to one side of 
the body. The eruption, however, often laps a little over the middle 
line, owing to the interlacing of the nerve filaments of the two sides 
of the body, but it can not continue around the body. Where there is 
a double zoster at the same line, as is reported, it will make a complete 
circle, or girdle, around the body; and these cases are not any more 
dangerous than others, notwithstanding the popular superstition to the 
contrary. The eruption may also follow any nerve line, and is not 
uncommonly seen along the limbs, and, especially in adults, along the 
tract of the cranial nerves. The separate lesions begin with one or 
more inflamed patches, tender to the touch, as if burned or scraped, and 
giving the sensation of heat and burning to the patient. Within a 
'few hours, minute points can be seen, which soon develop into vesicles, 
and may be closely set or scattered. The eruption is developed first 
near the root of the nerve, the patches or the more distant portion fol- 
lowing even some days later; in some places the eruption may stop 
short at the erythematous stage. It takes from three to ten days for 
the disease to reach its height, and about the same length of time for 
the lesion to dry up, although often the crusts may remain adherent for 
three weeks or more, and if the surfaces are irritated, ulceration may 
follow, which will take a longer time to heal. The amount of the 
eruption varies in different cases. In some there will be a broad band 
over the affected surfaces, with the groups of vesicles almost or quite 
touching one another ; in other cases the inflamed patches and groups of 
vesicles may be small and separated some distance apart, and occasion- 
ally but a single group or two will appear, perhaps with some ery- 
thematous redness between. 

Diagnosis. — The one-sided character of the eruption is always a 
striking feature, as also the grouping of the lesions along the nerve 
tracts. " Even early in the course of the disease, the erythematous 



Erythema, 743 

patches are tender to the touch and very sensitive, and accompanied by 
more or less neuralgic suffering. 

Prognosis. — Zoster, or shingles, offers a favorable prognosis. Scar- 
ring may result about the face, and may prove troublesome ; and when 
the eruption is located about the eye, that organ may be endangered; 
a certain amount of neuralgia may also persist after the eruption is 
cured. Neither of these features is common in children. 

Treatment. — Very little internal treatment is required other 
than to meet symptoms, as internal medication can influence but slightly 
the course of the disease. The neuralgia will require nerve tonics, 
especially quinine. A sugar of lead and laudanum lotion gives relief, 
and hastens the eruption in drying down, followed by oxide of zinc 
ointment. 

Ijfc: Plumbi acetas 3ij 

Tr. opii Sijss 

Aq use, ad . 3 vi 

M. et ft. lotio. 

Saturate a small bit of absorbent cotton, and lay it over the affected 
parts during the day, and at night apply oxide of zinc ointment. 

li: Zinci oxidi 3jss 

Vaseline 3j 

M. et ft. unguentum. 

Every morning wash the affected part very carefully (not remov- 
ing the scab) with a little castile soap and warm water; dry it, and 
apply the lead and laudanum lotion. The affected part must be bound 
up to prevent rubbing. The clothing may slip over it and cause irri- 
tation and pain. Some authors recommend fine starch or rice powder 
with a little morphine and zinc oxide ; dust thickly, and put on absorb- 
ent cotton and a bandage to prevent rubbing or friction from the cloth- 
ing. This dressing may remain intact several days ; when taken off, the 
eruption will be found quite dried up. If the vesicles should break, 
and the cloth stick to them, remove the cotton by soaking, and then 
apply fresh powder and a thin layer of absorbent cotton, which may be 
allowed to dry on, and may even be left until the surface is entirely 
healed. Where the pain is great, the galvanic current, applied directly 
over the lesion, will give relief, and will arrest the erupticn. In apply- 
ing the galvanic current, first apply a ten or twenty per cent solution 
of cocaine, for about five minutes, over the affected part ; then put the 
positive pole over the part affected, and the negative pole may be put 
somewhere along the spine, or may be placed over one of the lesions if 
not too near the positive. Apply for seven minutes or more over each 
group of lesions until all the affected parts have been treated. Then 
after the treatment apply oxide of zinc ointment or the powder already 
prescribed. 



744 Erythema. ' 

pemphigus. 
(I will quote from Dr. L. D. Bulkley.) 

Definition. — Pemphigus is an acute or chronic inflammatory dis- 
ease of the skin, characterized by the successive formation of bullae of 
various sizes generally upon a slightly inflamed base. 

Etiology. — Pemphigus is essentially a disease of lowered vitality, 
and most probably of nervous origin; in adults it not uncommonly fol- 
lows nerve exhaustion. In size the bullae may vary from that of a 
small pea to that of half the size of a large egg, generally rising in 
globular form abruptly from a slightly inflamed base. 

Pathology. — Little is said to be known of the real pathology of 
pemphigus. 

Symptomatology. — The three forms of pemphigus present such 
different phenomena that they require separate description. 

Acute Pemphigus. — This is the form of disease which is seen 
principally in children, and as pemphigus neonatorum often proves 
very fatal, occasionally appearing almost as an epidemic in lying-in 
institutions, occurring principally in feeble and ill-nourished children 
and amid unsanitary surroundings. Cases of acute pemphigus may 
differ greatly in severity, from mild cases where a comparatively few 
bullae develop on different parts of the body, the disease running a 
favorable course in two or three weeks, to severe and fatal cases, which 
may take on a gangrenous aspect, — pemphigus gangrenous, — the child 
perishing in ten or twelve days. Pemphigus is apt to follow con- 
valescence from acute febrile diseases, as scarlatina and measles, and 
in young infants. 

Chronic Pemphigus. — This is the more common form in adults, 
and it occurs more or less frequently in children. The eruption gen- 
erally begins quite acutely, with the outburst of one or several bullae, 
which may appear suddenly as small, clear, globular vesicles, almost 
as if produced artificially with a drop of scalding water. They enlarge 
rapidly, and in a single day may attain the size of a small egg. The 
lesions never run together, and seldom touch each other. 

In some cases the crops of vesicles will appear in rapid succession, 
each day producing a number ; in other cases their development will be 
more tardy, and one crop will almost dry off, when a fresh one will 
appear, and thus the disease may be prolonged indefinitely. The 
lesions may appear upon the lips and tongue, and in the buccal cavity 
and pharynx, rendering deglutition and talking very difficult. The 
amount of distress which may be caused by this disease is very great, 
the sufferer being often unable to lie in any position, or to make any 
movement without tearing the raw surfaces left after the bullae. If 
not checked by treatment, these patients succumb, perhaps after 
months, worn out by constant distress and by a diarrhea which can 
scarcely be checked. 



Erythema. 745 

Diagnosis. — This may sometimes be very difficult, and care should 
always be exercised to eliminate the other conditions in which bullae 
may appear. Thus we may have them from artificial causes, as burns, 
chafing, or irritating external applications, also from certain drugs 
taken internally. They are also seen sometimes in erythema and urti- 
caria, also in eczema, and occasionally about the hands and feet in 
scabies. Herpes zoster and hesper iris may present quite large bullae, 
as also varicella and impetigo contagrasa. They are sometimes seen 
in erysipelas, and finally are not uncommon in infantile syphilis. 

Prognosis. — This will vary greatly according to the individual 
case, and must always be given very guardedly, for few diseases run a 
more uncertain course than pemphigus. Relapses may come when 
least expected, and no reliable indications can be stated from which one 
might judge certainly of a favorable course of the disease. The large 
majority of cases recover. 

Treatment. — Arsenic appears to have the most controlling influ- 
ence over pemphigus ; but to be of real value it should be given freely 
and fearlessly. It is especially serviceable in children, and is remark- 
ably well borne by them. It should be given, diluted in at least one- 
quarter or one-third of a goblet of water, every two or three hours, 
in doses increasing in quantity, until the disease yields or until some 
signs are given that it disagrees with the patient. Usually diarrhea will 
be the first sign of disagreement; and even then, if the disease is not 
checked, it may often be continued freely, and this action may be 
checked by adding a little opium, which also acts favorably on the 
disease. Attention should be given to the general state of the patient 
and supporting treatment given; but alcohol is prejudicial to the 
eruption. 

Locally, great difficulty is often experienced even in making the 
patient tolerably comfortable. The blebs do better if punctured near 
the base with a fine needle in one or two places and the serum allowed 
to ooze out, and the covering made to rest on the base of the bulla. 
This should be preserved in every case as long as possible. Some^- 
times thin layers of absorbent cotton serve the best. When there is 
a raw surface, a very mild ointment of oxide of zinc, half a dram to 
the ounce of rose-ointment, or cucumber-ointment, with half a dram 
of tincture of camphor, or a few drops of carbolic acid to the ounce, 
will afford most relief. When there is much denuded surface, comfort 
has been obtained by a continuous warm bath, in which the patient 
may lie on a mattress, Hebra keeping some patients in this condition 
for many months in comparative ease ; but much use of water, except in 
this manner, is prejudicial in these cases, and rather tends to the 
development of new blisters. 

ECZEMA. 

Synonyms. — Salt-rheum, moist tetter, scall, milk crust. 
Definition. — Eczema is a constitutional affection in which it is 
often impossible to trace any local cause for the eruption. 



746 Erythema. 

Foremost among all diseases of the skin in importance, both from 
the members affected and the distress occasioned, must always come 
this ever-varying eruption — eczema. It attacks all classes and condi- 
tions, from the cradle even to the grave, and appears about equally in 
both sexes. Eczema is defined as a non-contagious inflammatory dis- 
ease of the skin, of constitutional origin, acute or chronic in character, 
manifesting any or all of the results of inflammation at once or in 
succession, and accompanied with burning and itching; a tendency to 
exude a serous discharge, which stiffens linen and dries into scales or 
crusts, and in later stages, an infiltration or thickening of the skin, 
which then cracks, producing painful fissures. 

^ The earliest local phenomena in eczema are nerve and capillary 
disturbances, and the skin lesions are to be looked upon as secondary 
to these. Eczema has been well spoken of as catarrh of the skin ; the 
exudative feature is rarely absent at some period of its course. 

Symptoms. — There are six general symptoms of eczema. These 
are : First, itching, pricking, or burning pain ; second, redness from 
congestion; third, papules, vesicles, pustules, or exudation; fourth, 
crusting and scaling; fifth, infiltration, or thickening; sixth, fissures, 
or cracks. Itching is the most prominent and constant symptom in 
eczema, which may be preceded by, or give place to, a burning pain. 
The itching is always worse when exposed to the air. 

There is usually an elevation of temperature in the part affected 
with redness from congestion. This redness disappears momentarily 
on pressure ; but after it has continued for some time, a yellowish stain- 
ing remains. 

The exudate of eczema, which stiffens and stains linen, has a very 
strong tendency to dry into crusts and scales. If a discharging sur- 
face is left exposed to the air, it soon becomes glazed over and slippery, 
but dry in place of being sticky. This coating increases from beneath, 
and forms scales, or crusts, of varying thickness, especially in infants, 
as in "milk crust" upon the scalp. The masses may be very great, and 
on removing them the surface is still moist beneath. 

Infiltration, or thickening, belongs to chronic eczema, but is seen 
more or less in every case. The skin acquires a hard, leathery condi- 
tion, and this thickening may extend even through the entire corium, 
and on the legs. 

Fissures, or cracks, are closely connected with the infiltration or 
leathery condition, and they occur and pass into subacute eczema. 

Subacute Eczema. — This term refers to a less inflammatory con- 
dition, with a reddened, itchy surface, and moderate thickening. The 
diseased portions may be moist, tending to become scaly or crusted, or 
they may be hard and papular, exuding a glairy fluid when scratched. 

Chronic Eczema. — This term is applied both to an eruption of 
long duration, and to the condition which usually obtains in old cases. 
Chronic eczema is characterized by reddened and thickened skin, which 
itches furiously and may desquamate freely, or exude if scratched. 



Erythema. 747 

Where there is motion, there is a tendency to fissures, which raay be 
very painful. Itching may be absent in particular cases of chronic 
eczema. 

The lines of demarcation between these three conditions are not 
well defined ; but the distinction between the acute, inflammatory state 
and the chronic, indolent condition, is of great importance. In the 
acute stage the mildest, most soothing, and astringent applications are, 
called for ; in the chronic, very severe stimulation may be required. 

We have four special varieties, or conditions, of eruption, which 
relate to the anatomical lesions constituting the eruption. These are 
eczema erythematosum, eczema papillosum, eczema vesiculosum, and 
eczema pustulosum. There are other forms which are commonly recog- 
nized as eczema, namely, eczema madidans, eczema squamosum^ 
eczema sclerosum, and eczema fissum. • 

Eczema Erythematosum. — There is always some infiltration or 
thickening of the part, and the surface has a harsh, leather feel, and 
may be more or less scaly. 

Eczema Papillosum. — This lesion is composed of papules, perhaps 
existing alone or combined with other former conditions, or with 
occasional vesicles. 

Eczema Yesiculosum. — This form is comparatively rare, and is 
generally acute. More commonly the vesicles have broken down 
already into moist surfaces, or hard patches, when presented for treat- 
ment. Where the epidermis is thick, as en the palm surface of the 
hand and fingers, the vesicles appear in pearly or boiled-sago-like points. 
The burning and stinging are generally relieved when vesicles are 
formed, and often cease when they discharge. 

Eczema Pustulosum. — Here pustules take the place of vesicles, 
either from the intensity of the inflammation, or from the lowered or 
strumous condition of the patient. Pustular eczema, as eeen in "milk 
crust" in infants, presents a mass of yellow crusts only. Pustules of 
hairy parts seldom itch much. 

Eczema Madidans. — This results from a shedding of the epi- 
dermis, which may either result 'from a chronic eczematous process or 
may occur acutely. It is often observed typically on the lower legs. 

Eczema Sclerosum. — This relates to the thickening of the skin, 
which forms almost the sole feature of the case, as upon the palms, the 
soles of the feet, and the finger-tips. This form leads to the next. 

Eczema Fissum. — This presents cracks of varying size and depth, 
often very painful, as is seen on the ends of the fingers. 

The face and scalp are very common seats of the eruption in 
infants. At first it appears as an itchy, reddened patch, with a few 
papules, which are quickly torn, and a raw exuding surface results. 
This soon becomes covered with crusts, and is torn off by scratching. 
The surface rapidly increases in size, until a large portion of the face 
and scalp may be affected. In adults the eruption commonly assumes 
the erythematous or papular form on the face, or a pustular form upon 



748 Erythema. 

hairy parts. Erythematous eczema of the face is very often mistaken 
for erysipelas or erythema. 

Eczeina of the eyelids is sometimes a very troublesome affection. 
The edges of the lids are thickened and red, and the lashes glued 
together. 

Eczema of the lips may exist alone, affecting the skin or the bor- 
der of the lips. Eczema is rebellious about the mouth, owing to the 
constant movements of the part. Eczema of the upper lip is often 
connected with an irritating discharge from the nose. 

Eczema of the ears and behind the ears is not uncommon in chil- 
dren ; it is also common in adults. When acutely affected, the ears are 
greatly swollen, hot, and painful ; in a chronic state of eczema they are 
moist, thickened, and itchy. Behind the ear the eruption is very apt 
to linger for a long time, causing annoying cracks. 

Upon the scalp eczema has a pustular, moist, exuding, and dry, 
scaly appearance. 

Pustular eczema is common in young persons, presenting separate 
pustules, or more often only crusts, which mat the hair together, with a 
moist surface beneath. 

Squamous or scaly eczema exhibits many phases and degrees , 
Often it is but a later stage of other forms, slowly increasing from a 
moderate scaling, until what first appears as a mild dandruff becomes 
annoying in the extreme, by the itching and constant shedding of scales. 

Diagnosis. — Eczema of the face may be confounded with ery- 
thema, acne, rosacea, and erysipelas ; in the beard, with sycosis and 
barbers' itch (tinen barbae). Upon the lips it may be mistaken for 
syphilitic mucous patches, especially at the corners of the mouth, and 
herpes labialis. It is contagious in the same person by scratching; 
the patient must not scratch. Mothers and nurses will carry it under 
their finger-nails to other parts of the body. 

Treatment. — Eczema indicates feeble health. It is therefore 
important that the general rules of hygiene should be enforced, and 
that a judicious dietary should be prescribed. There are no specifics 
for the disorder, and consequently each case should be treated accord- 
ing to the general diathesis of the patient, and complicating agencies 
must be removed or ameliorated wherever possible. In quite a large 
number of cases, internal remedies are not called for, either because the 
disease has been evoked by local causes, or because the internal exciting 
cause has ceased to be operative, and there remain only the effects, 
which must be removed by local means. In acute vesicular erythem- 
atous and papular eczemas, lotions and powders of a soothing and 
astringent character are most invariably indicated, whereas in subacute 
forms of the disease, especially where there is much exudation and 
crusting, ointments of various kinds, such as lead, zinc, and mercury, 
are more efficacious. In scaly eczema, the tars, in salve forms or in 
solution, are very valuable. In chronic cases, where the skin is much 
infiltrated, the object of the treatment is to cause reabsorption of 



Erythema. 749 

effused material by such means as potash soap or solution of caustic 
potash. The most efficient means is the galvanic current of electricity, 
the positive pole active. Place the positive pole (after first having 
covered the zinc electrode with eight or ten thicknesses of surgeon's 
lint) over the thickened surface, the negative pole some distance from 
the positive. Give as high amperage as can be borne without pain, 
usually from five to thirty milliamperes, from five to fifteen minutes. 
This treatment may be given every day for eight or ten days, then every 
other day until infiltration is absorbed. Sometimes only a few treat- 
ments are required. 

After each treatment apply the usual remedies. A remedy of 
almost universal application is: — 

Iji: Zinci oxidi 3iv 

Pulv. calamine prsep 9iv 

Glycerini 3j 

Liq. calcis 3vii 

Mix, sig., shake. 
Mop on with a rag several times daily ; under some circumstances 
it is better to dip cheese-cloth, cut into suitable strips, in this lotion, and 
bind them on neatly with a bandage. Black wash, pure or diluted, is 
of value, and solutions of lead and opium of varying strength. 

Ijfc: Opium tincture 3iv 

Sugar of lead 3j 

Aquae purse 3iv 

Mop on with a rag several times a day. 

Powders are also of considerable efficacy at times: — 

]J: Oxide of zinc 3ij 

Lycopodium ,lj 

Mix. 

Keep the parts powdered. 
Or:— 

1>: Oleate of zinc 3J 

Thymol , gr. j 

Mix. 
Keep the part powdered. 

Local eczema from the pressure of braces, trusses, splints, etc., 
may easily be prevented if the underlying surfaces are protected with 
simple dusting powder. Borated talcum is an efficacious powder. If 
the skin has become somewhat infiltrated, Lassar's paste will speedily 
restore it to a normal condition: — 

I£: Acidi salicylici gr. x 

Pulv. Amyli, zinci oxidi, aa JJiij 

Vaseline, q. s., add Jj 

Mix. 



750 Erythema. 

When made properly, this is unequaled as an application for all 
forms of intertrigo, or chafing; but if illy prepared and gritty, it acts 
as a direct irritant. 

In local patches of eczema, attended by more or less crusting and 
a degree of infiltration, unguentum vaselini plumbicum is of great 
value. This is made by melting together equal parts of vaseline and 
old lead plaster. It should be spread on a strip, or strips, of muslin, 
and then bound on with a roller bandage; when there is itching, one 
per cent of carbolic acid may be added to each ounce of the salve. 

Tannin ointment is especially suited to the scalp. It should be 
applied freely and left on. 

1>: Tannin v 3j 

Lanoline 3j 

Mix. Apply several times a day. 

The part must be very seldom washed ; but when washed tar soap 
should be used, and the ointment re-applied within a few minutes. 
For the treatment of eczematous ulcer of the legs, there are innumer- 
able remedies. The best will be mentioned. As eczematous ulcers 
nearly always occur in those affected with varicose veins, it is impor- 
tant to attend to this condition. The most effectual manner of reliev- 
ing the chronic congestion caused by the dilated or varicose veins, is 
rest in bed with the limb slightly elevated above the body. The neces- 
sity of earning a livelihood often prevents the patient from receiving 
the benefit of this rest-cure treatment; hence we have to attempt to 
accomplish the same thing in another way, namely, with the elastic 
bandage. The bandage may consist of heavy white flannel, or Mar- 
gin's rubber bandage may be used. The rubber bandage is best ; but 
some prefer the white flannel bandage, as it does not hold the secre- 
tions like the rubber bandage. Before applying the rubber bandage, 
certain precautions are to be observed. The leg must first be dusted 
w T ith a powder such as has been recommended above for use under 
trusses. A loose white cotton stocking is then drawn on, and over this 
the bandage is applied. In using either bandage, two things must be 
attended to : First, so regulate the tension of the bandage that while it 
is being applied firmly from the toes to the knee, the pressure gradually 
diminishes from below upward ; second, always apply the bandage 
before the patient arises in the morning, and remove it only after the 
patient has retired for the night. Where constant pressure is wanted, 
it may be necessary to re-apply the bandage at night in bed. 

The treatment of the ulcer itself depends on the condition pre- 
sented. In small, shallow, irritable ulcers, a soothing treatment may 
be required. For this purpose unguentum vaseline plumbicum, spread 
on cloth and neatly applied under an elastic bandage, is excellent. In 
other cases, where the ulcer is deeper, more chronic, and indolent, 
stimulation is necessary. The ulcer should first be carefully washed 
with a solution of carbolic acid, and its floor and sides slightly dusted 



Erythema. 751 

with iodoform or aristol. The ulcer, and the surrounding skin as well, 
should then be dressed with unguentum vaseline plumbicum. In case 
there is a free purulent discharge from the ulcer, it is important to try 
to secure a more healthy action by careful antiseptic dressing. The 
leg should first be carefully cleansed with soap and water, and then 
both ulcer and leg washed with a 1 to 1,000 solution of bichloride of 
mercury; a dressing — iodoform or bichloride gauze — is then applied, 
and a crinoline bandage put on. The frequency with which the dress- 
ings are made, will be regulated by the amount and character of the 
discharge ; twice a day is usually sufficient. In old ulcers the border 
often becomes so thickened and so adherent to the deeper tissues as to 
prevent cicatrization. 

Pressure, properly applied, is most efficacious in relieving this 
condition. A rubber bandage (Martin's) may be applied, or the ulcer 
may be carefully strapped with surgeon's plaster. At night the rub- 
ber bandage may be removed, washed, and aired all night, and in the 
morning re-applied while the patient is in bed, after the dressing for 
the night has been removed, and the ulcer and leg cleansed and dressed 
antiseptic ally. 

Treatment for eczema of the face is difficult, and bears stimula- 
tion poorly. During the more acute stages, soothing lotions and oint- 
ments are required. 

li: Pulverie calamine preparatse 5jss 

Zinci oxidi 3j-3ij 

Glycerinse 3j-3iij 

Aquae rosse 3iv 

M. et ft. lotio. Mop on with soft rag. 

Another valuable lotion, cooling and antipruritic, is: — 

$: Pulverie calaminse preparatse 3j 

Cretse preparatse 3j-3ij 

Acidi hydrocyanici diluti - 3ss 

Glycerine , 3ij-3iv 

Liquoris calcis 3iij 

Aquae sambuci, ad %yi\\ 

M. et ft. lotio. 

Sig. : Mop on with a soft rag several times a day. 

(Tannin Ointment.) 

]J: Acidi tannica 3j 

Unguentum aquae rosse *j 

M. et ft. unguentum. 

Sig. : Wash with tar soap ; apply the ointment ; wash very seldom ; 
keep ointment applied. 

The following is efficacious in an erythematous condition of the 
face : — 



752 Erythema.* 

(Diachylon Ointment.) 

\y. Zinci oxidi 3j-3ij 

Loquoris plumbi subacetatis dil.. . . 3ij 

GlycerinaB 3ij-3iv 

Infusi picis liquidse, ad jfiv 

M. et ft. lotio. 

Sig. : Apply several times a day. 

A very soothing ointment for eczema of the face is the follow- 
ing:— 

Jfc: Zinci oxidi. 3j-3jss 

x Unguenti aquae rosse 3j 

M. et ft. unguentum. 

Keep the affected parts anointed. 

In eczema of the beard shave daily with Pear's transparent soap, 
and use continuously an application of a calalamine or diachylon oint- 
ment : — 

1},: Acidi carbolici gr. v to viii 

Pulveris calaminae prep 3ss-3j 

Zinci oxidi 3ss-3j 

Unguenti aquae rosaa 3j 

M. et ft. unguentum. 

Sig. : Keep continuously applied. 

The following ointment is beneficial in chronic eczema of the 
beard : — 

$: Emplastri diachyli gj 

V^aseline 3j 

M. 

Dissolve with heat and stir until cold; keep applied. 

In eczema of the hands the eruption is very rebellious, owing to 
their exposure to air and water, the great motion of the parts, and the 
difficulty in keeping dressing applied. Acute eczema may exhibit 
much inflammation and considerable oedema; more commonly the 
eruption is subacute or chronic, with the repeated production of papules 
and raw, hard patches, with fissures. On the palms and the soles of 
the feet chronic eczema presents a stiff, hard surface, reddened or not, 
with ragged scaling and cracks, usually very painful, combined with 
itching, which may be distressing. The diagnosis between this and 
palmer syphilis is often very difficult. As a rule, the eruption of 
syphilis is more sharply defined than that of eczema, with a decided 
tendency to clear in the center and to spread peripherally. The mar- 
gin of the syphilitic eruption is composed of separate elements, papules, 
or tubercles, and cracks are usually through these; whereas those in 
eczema may occur anywhere and in any direction through the thick- 
ened skin. 



Erythema. 753 

Eczema of the arras exhibits the features of eczema elsewhere. At 
the bend of the elbow it is apt to present evenly reddened surfaces, very 
itchy, exuding freely when scratched ; elsewhere the eruption is usually 
papular or in patches of reddened and moderately thickened tissue. A 
very scattered papular eruption of the forearm suggests scabies. 

Treatment. — This varies greatly with the condition present; in 
the more acute form of the eruption, enveloping the hand and arm in 
a bag containing buckwheat flour is most serviceable. (Bulkley.) 
Cooling and astringent lotions and ointment are called for. 

Dr. J. Hutchinson recommends tar as the best and only remedy 
to cure eczema. In some cases he recommends a very weak solution in 
the acute stage, and one a little stronger in the chronic. For a change 
in some cases, Dr. J. Hutchinson uses acetate of lead lotion first before 
using the tar lotion. 

Dr. A. Van Harlingen recommends lotio migra, or black wash, as 
one of the best lotions in very acute eczema. This is made, as is 
known, of calomel and lime water. 

Ij,: Mild chloride of mercury, or calomel, .gr. lxiv 

Water Jss 

Solution of lime-water fL.^xvi 

M. et ft. lotion. Shake well before using. 

It may be mopped on with a soft rag, or bits of soft rag may be 
wet with the lotion and laid over the part. The rags should be allowed 
to become nearly dry, and then should be wet again. They must not 
be allowed to dry perfectly before wetting, as they will be apt to stick 
to the skin, causing pain and irritation when removed. Sometimes 
dabbing on the black wash for some moments may be followed by some, 
mild ointment, such as oxide of zinc made with pure vaseline, one and 
a half drams of oxide of zinc to one and a half ounces of pure vaseline. 
Keep it applied. To remove the ointment from the part when neces- 
sary, cleanse with warm water and sulphur soap, dry with a soft rag, 
apply the lotion for five minutes or more at a time, then put on the 
ointment, also spread some ointment on a soft rag and lay it over the 
part. After the eczema begins to pass into the chronic stage, twice a 
day is often enough to apply the lotion. During the acute stage the 
lotion should be kept applied through the day, and the ointment put on 
at night. If the itching annoys the patient during the night, apply 
the ointment. 

In the subacute state an ointment of tar is very serviceable. In 
chronic forms the compound tincture of green soap is an efficacious 
stimulant. 

I>: Olei cadini, 
Saponis veridis, 

Spiritus vini rectificati, aa 3j 

Mixr. filtra et addi, 

Spiritus lavandulse 3ij 

M. et ft. lotion. 

48 



754 Erythema. ; 

Use as a stimulant in chronic eczema. 

The author has found sulphurous acid diluted a very serviceable 
lotion in old chronic cases of eczema. 

1>: Acid sulphurous 3ij-3iv 

Aquae 3ij to ijss 

M. et ft. lotion. 

Sig. : Apply it for ten minutes at a time to the affected part r 
after first having washed the part with sulphur soap. After the lotion 
has been applied for ten minutes, put on oxide of zinc ointment : — 

11: Zinci oxidi 3jss 

^ Vaseline 3J 

M. et ft. unguentum. 

Two to three times is often enough in twenty-four hours to use t he 
lotion; keep the ointment applied. 

Eczema of the anus and genital region is most intractable if 
wrongly treated, and is very curable if managed rightly. The erup- 
tion manifests various degrees of severity, from a moderately itchy, 
sodden condition around the anus to a severely raw, eczematous surface, 
involving many square inches of this region. 

Treatment. — The internal and dietary treatment is of the greatest 
importance; then with proper local measures the eczema will soon be 
under control. A weak solution of liquid tar is applied, after the- 
part has been cleansed with tar soap and warm water. Then follow 
with tar and zinc ointment : — 

%\ Unguentum picis liquids 3i to iii 

Zinci oxidi 3i to 1J 

Unguenti aquae rosaa, ad ^j to iss 

M. et ft. unguentum. 
Use antipruritic, and protectives. (See article on The Rectum.) 

INFANTILE ECZEMA. 

Eczema may be acute, running its course in a few weeks and then 
permanently disappearing, or it may be chronic and continuous, or 
recurring through years. It may occur in small patch, single or mul- 
tiple, or more rarely covering extensive surfaces. It is never con- 
tagious. 

Etiology. — The etiology of eczema in children is not understood, 
especially infantile eczema, which is by no means thoroughly under- 
stood. (Bulkley.) 

Prof. James C. White, of Boston, draws attention to external fac- 
tors in the etiology of eczema, which come into play the moment an 
infant is born into the world. "From its prolonged, placid, sub- 
aqueous life it [the infant] emerges into sudden contact with the more 
stimulating properties of an entirely different element, — the atmos- 
pheric ether. For the first time its capillaries dilate to their fullest 



Erythema. 755 

extent under the new condition of respiration, and independent and 
intensified circulation, and spasmodic vocalization. So, too, its glandu- 
lar systems are called upon to adapt themselves to the strange external 
surroundings." 

''Moreover, at this critical period the infant makes an abrupt 
acquaintance with the foreign materials of the outer world. Anointed 
at once with fats, too often with rancid vegetable oils, then rubbed with 
a chemical compound, more frequently than otherwise composed of 
impure constituents and so imperfectly combined that an excess of 
alkali is at liberty to exercise its caustic action upon the susceptible 
skin ; then plunged into water of varying temperature, and briskly 
rubbed ; and finally received in a coarse blanket and dried by friction, 
it may be with a coarse towel, — such is often the first treatment the 
skin receives. 

"Later the dressing: Around the abdomen is bound tightly a 
broad flannel band, between its legs are stuffed thick folds of napkin, 
and about its lower extremities again the rough contact with a woolen 
petticoat, — all ingeniously adapted to irritate the skin by overheating, 
pressure, and rude friction. It is not surprising under these circum- 
stances that the skin should resent such irritating surroundings, and 
should within a few days develop a congestion of greater or less extent, 
or a mild follicular inflammation which may develop into the more 
serious and permanent form of eczema." 

But other exciting causes are at work. The discharges arc 
often allowed to remain too long unremoved. The irritating foecal 
matter and urine, kept in contact with the skin by thick folds of 
napkin, can scarcely fail to produce the erythematous condition 
called intertrigo, or chafing, from which to eczema is but a step. 
Among the poor, neglect in these matters is a common cause of eczema, 
to which must be added the regurgitation of milk allowed to saturate 
the clothing about the neck throughout the day and night. Imperfect 
removal of the smegma at the first washing, and too warm and thick 
clothing, inducing profuse perspiration, may also be exciting causes of 
eczema. Eczema affects all classes of society alike ; it occurs at all 
seasons of the year ; it comes in children of all degrees of health, in the 
perfectly sound as well as in the feeble, and, says Professor White, "in 
equal proportions among bottle babies and those fed at the breast." 

Diet. — A hygienic mode of life, together with appropriate aid 
from medicine, accomplishes for these little ones what local treatment 
has failed to do. 

Keating says : "By no means do I consider eczema a scrofulous 
disease; but one thing I do feel sure of is that eczema, or at least the 
predisposition to eczema, is induced by any cause which depraves the 
general nutrition, and that the various signs which are generally recog- 
nized as indicative of scrofulous tendency, go hand in hand with symp- 
toms of impaired nutrition, and point also, when found in connection 



756 Erythema. • 

with eczema, towards ascertaining a plan of treatment which may be 
called anti-scrofulous." 

Dyspepsia, too, is a predisposing cause of eczema. 

Symptoms. — In children under five years of age the eruption of 
eczema is exhibited in its typical form, as far as the acute, raw, and 
exuding aspect are concerned. Beginning with a comparatively small 
amount of papular eruption, the condition may rapidly extend until 
the entire scalp and face, also the arms, legs, and much of the body, are 
the seat of a diseased cutaneous action. 

The surface of exposed parts is generally covered with crusts, 
which are frequently torn off, leaving a bleeding and exuding corium ; 
covered parts become more dry, generally adhering to dressings; and 
when these are forcibly removed, they exhibit a reddened, papular 
surface, with numerous excoriated points, which sometimes bleed. The 
itching of infantile eczema is generally frightful, and the little suf- 
ferers become frantic in their endeavors to get relief. 

Treatment. — In the local treatment of infantile eczema the utmost 
care must be exercised to avoid overstimulation of the affected parts. 
Soothing and astringent remedies must be used to give relief. The 
diet must be carefully directed, and the parts properly protected. 
Tar and zinc ointment, — unguenti picis liquids one to three drams, 
zinci oxidi half to one dram, unguenti aqua? rosa? ad one ounce, mixed 
into an ointment, — is a safe and valuable remedy if efficiently applied. 
Spread on surgeon's lint or a piece of linen, and bind on. This should 
be removed twice daily, and on exposed surfaces the ointment is 
re-applied as often as rubbed off, even many times daily, to exclude the 
air. 

Zinc and bismuth ointment, to which a little camphor may be 
added, is also useful, — zinci oxidi one dram, bismuth subnitrate one 
dram, unguenti aquse rosse one ounce. Mix. Spread on lint, and keep 
applied. 

The following ointment is very soothing and astringent in acute 
inflammatory conditions : — 

Ijt: Bismuth oxidi 5rj 

Acidi oleici 5ij 

Unguenti petrolei Jij + 3ij 

Cera? albre 5vj 

Olei rosaB drops vj 

Rub up the bismuth, or zinci oxidi, with the oleic acid, and let 
it stand for two hours ; place in a warm-water bath ; add the vaseline 
and wax, and when dissolved stir until cold, and add the oil of roses. 
Apply on linen or surgeon's lint. 

Air and water are highly injurious to eczematous skin, and wash- 
ing should be avoided; but when it is absolutely necessary, the part 
should be again instantly and thoroughly protected by ointment, after 
being very carefully and rapidly dried without friction. Gently touch 
with a dry, soft cloth, to dry it after washing. 



Erythema. Ibl 

When there is evidently much itching and burning, but no dis- 
charge, the following combined powder gives great relief. It should 
be applied on raw surfaces: — 

1£: Pulv. camphoric .... oj 

Pulv. amyli, 

Pulv. zinci oxidi, aa sss 

Mix. 

These powders may be dusted on, may be rubbed abundantly with 
the wooly side of a piece of patent lint, and bound upon the skin. 

Eczema about the buttocks, genitals, etc., will sometimes bear the 
application of tarry preparations, especially the tar and sulphur oint- 
ment, made as follows: — 

#: Sulphur prsecipitat, 

Ungt. picis liquidse, aa 3j 

Ung. ziuci oxidi Ijss 

Mix. 

This should be used in small quantities about the genitals. 

When the eczema is acute, warm medicated baths are often of the 
greatest benefit in connection with the other forms of treatment. Two 
ounces of carbonate of sodium dissolved in about fifteen gallons of 
water, with a half pint of clear starch stirred through the water, is a 
good formula. 

When the child is taken out of the bath, any appropriate applica- 
tion of those mentioned above, may be used. 

Older children suffering from eczema may be treated in the same 
manner as adults. 

The general treatment of infantile eczema, though important, 
has nothing specific about it. It is directed toAvards removing all 
sources of irritation, internal and external, which may excite the 
inflammation of the skin, and towards improving the general nutrition 
when this is impaired. 

In early infantile eczema, digestive disturbances are very com- 
monly at the bottom of the disease, while in the eczema of older chil- 
dren some fault of nutrition must be combated. 

Prognosis.- — The prognosis of eczema in children is favorable. 
Most cases of infantile eczema can be cured in periods varying from 
a few weeks to months, if the source of irritation can be removed. 
When the eczema depends upon some general defect of the skin, as 
ichthyosis, the prognosis must be more guarded. In some cases relapses 
may occur at intervals during the whole period of childhood to adoles- 
cence, in spite of all treatment. 

ICHTHYOSIS. 

Definition. — Ichthyosis is a disease of the skin, marked by the 
formation of white masses of epidermis, which peel off like thin paper ; 
or of green, brown, or black masses firmly fixed to the skin and sep- 



i 



758 Erythema. 

arated from one another by deep furrows and lines. It affects, usually, 
the whole integument, is congenital, and of a decidedly chronic char- 
acter. 

Diagnosis. — The thickening of the skin, the large scales with well- 
marked lines separating them, the wart-like excrescences or ridges, sep- 
arated by furrows which pass deep down to the corium, are all very 
characteristic of this disease. Then its chronic and congenital char- 
acter will also assist in making a diagnosis. 

Treatment. — Internal treatment is said to be of little avail. Cod- 
liver oil has been found of benefit in some cases. The main object of 
the external management is to soften and get rid of the epidermal 
masses, and at the same time to make the skin more soft and pliable. 
An emollient application may be made of lamoline or glycerine, mixed 
with two or three parts of cold cream. Glycerine may be combined 
with oleate of bismuth. Equal parts of vaseline and glycerine of 
starch are recommended. 

Durhing recommends the following formula: — 

1£: Adipis benzoati 3ij 

Glycerini 11^x1 

Ung. petrolei Jss 

M. 

Sig. : Apply daily after washing with castile soap and warm 
water. 

There is no remedy which will prevent the return of the epidermal 
masses. The local treatment must, therefore, be repeated as often as it 
is found necessary. 

Prognosis. — Ichthyosis is an incurable disease. As a rule, the 
health of the patient is not otherwise injured. (J. E. Graham, M. D.) 
Nor does life seem to be shortened by it. The functions of the internal 
organs appear, as a rule, to be unaffected by it. 



CHAPTER LX. 
PARASITIC DISEASES. 

TINEA FAVOSA. 

Definition. — Tinea favosa is a contagious disease of the skin, due 
to the presence in the cutaneous structure of the vegetable parasite, the 
achorion schonleinii. Its usual seat is the scalp, although any part of 
the integument may be attacked. It is characterized by variously 
sized, circular, concave, yellow crusts, which are usually pierced by 
hairs. 

Tinea favosa is a dermatomycosis, having its seat in the hair- 
follicles, the hair, and the epidermis, more especially in the superficial 
portion immediately beneath the corneous layer. 

Diagnosis. — The diagnosis of f avus offers ordinarily no difficulty. 
The yellow color of the crusts, their circular cup-like shape, their 
friability, and their peculiar musty odor, are usually characteristic. 
In old cases, and especially in those attended with pus formation, it 
may be confounded with eczema, but the peculiar crusting, the involv- 
ing of the hairs, and the presence of more or less baldness, often with 
atrophy and superficial scarring, will serve to distinguish it from this 
affection. 

Prognosis. — Favus is a curable disease, but the length of time 
required to effect a cure depends upon the extent of surface involved, 
and more especially upon the duration of the disease. On the scalp 
a cure in four to ten months is said to be an average case, and may be 
considered to be a good result. Recent cases respond much more read- 
ily than those in which the disease has been long continued. On non- 
hairy parts of the integument, favus is usually readily and quickly 
cured ; when affecting the nails, however, it proves obstinate. 

Treatment. — This must be energetically carried out if a result 
is to be expected. The crusts are to be removed by means of oil appli- 
cations and soap and hot water washing. In cases where the crusts 
are more or less tenacious, instead of ordinary soap, sapo varidis may 
be employed with advantage. Subsequently the scalp is to be washed 
only at intervals of several days, in order that the remedy used mav 
thoroughly soak into the diseased parts. After removal of crusts, para- 
siticides are to be employed. In those cases in which a great part of 
the scalp is involved, drawing the hair between the thumb and side of 
a comb is advisable, the diseased hairs usually coming away with slight 
traction. The hairs are best extracted by means of forceps or tweezers. 

(759) 



760 Parasitic Diseases. 

This should be practised each day, and a parasiticide applied imme- 
diately afterwards. In all cases the remedy should be applied at least 
twice daily. The most valuable remedies are corrosive sublimate in 
the strength of one to four grains to an ounce of alcohol and water; 
oleate of mercury ointment from ten to twenty per cent ; sulphur oint- 
ment, citrine ointment, with one to three parts lard ; and carbolic acid, 
one to three drams to the ounce of lard or glycerine. Tar ointment 
is also valuable. 

In conjunction with active treatment of the diseased areas, a sat- 
urated solution of boric acid, or a strong carbolic-acid lotion, two to 
four drams to one pint of water, is to be employed as an application to 
the whole scalp for the purpose of preventing the spread of the disease. 
At the end of four to six weeks, treatment should be intermitted for 
several days, that the effect of the remedial applications may be ascer- 
tained. In favus of the nails, the oleate of mercury and corrosive 
sublimate solutions seem to be the most efficacious. These parts should 
be kept cut and scraped. 

TINEA TRICHOPHYTINA, OR RINGWORM. 

Definition. — Ringworm is a contagious disease of the skin, due to 
the presence of a vegetable parasite, the trichophyton. It varies consid- 
erably in its clinical aspects according to its seat and varieties. Tinea 
circinata, tinea tonsurans, and tinea sycosis demand, for practical pur- 
poses, separate descriptions. The last-named variety is obviously con- 
fined to adults. 

Tinea circinata, or ringworm, is caused by the growth of the fun- 
gus in the corneus layers of the epidermis. It is highly contagious, 
being readily communicable from person to person by direct contact or 
through the medium of various articles of clothing or of the toilet. It 
is confined to no age, but is by far most common in children. Sex is 
without influence. 

Diagnosis. — While the diagnosis is quite easy, yet there are cer- 
tain diseases, more especially eczema, psoriasis, and seborrhoea, which 
may more or less resemble it. From eczema it is to be distinguished 
by its circular shape, the sharply-defined margin, the peri pi 1 era 1 exten- 
sion, and the slight degree of inflammation. The circinate patches of 
psoriasis bear some resemblance, but the marked scaliness and the 
inflammatory symptoms, together with the presence of ordinary 
psoriasis spots, will serve to differentiate. 

Treatment. — The treatment of ringworm is usually attended with 
rapid results ; it is only in exceptional cases that the disease is obstinate, 
and this especially in strumous and debilitated patients. The remedy 
should be applied at least twice daily. If an ointment is employed, it 
should be rubbed thoroughly in ; if a lotion is used, it should be daubed 
on the patches for several minutes at each application. Hyposulphite 
of sodium, in solution or in an ointment, a dram to the ounce; corrosive 
sublimate, one-half to four grains to the ounce, in an ointment or in a 



Parasitic Diseases. 761 

solution ; sulphur ointment, full strength or weakened with two parts of 
lard ; ammoniated mercury ointment, full strength or weakened accord- 
ing to the condition of the child, are useful applications. For obstinate 
cases, paint the patches with collodion containing a dram of chrysarobin 
to the ounce, or with the tincture of iodine. Infants and young chil- 
dren should always be treated with care. Do not use any harsh reme- 
dies, but weaken the solutions and ointments to suit the case. For 
strumous patients, internal remedies, such as cod-liver oil, iron, and 
other alternative tonics, are called for. 

The nails, when affected, should be kept closely cut and scraped, 
and one of the above ointments or lotions frequently applied. 

Ringworm of the Scalp. — In some cases this disease may exist in 
the form of disseminated patches, each patch involving a few or a lim- 
ited number of follicles. In this form, as the scaliness is slight in 
some cases, and the number of stumps or elevations is small, the 
disease may readily escape detection unless great care is exercised. 

Diagnosis. — The rounded, marginate, scaly plaques, from which 
many hairs have fallen out, the numerous broken-off hair stumps, the 
peculiar appearance of the affected part produced by the minute pro- 
jecting cones of the epidermic scales, are features sufficiently char- 
acteristic to prevent error in the diagnosis. 

Treatment. — Prognosis as to the ultimate cure is favorable, but it 
is frequently exceedingly rebellious to treatment. Repeated relapses 
will occur. In an average case a cure may usually be effected in two to 
six months. 

Frequent application of parasitic remedies should be made to the 
whole scalp, in order that the spread of the disease may be prevented. 
For this purpose a saturated solution of boric acid, a two per cent solu- 
tion of carbolic acid, or a weak lotion of corrosive sublimate, may be 
employed. The scalp should be washed at intervals of several days, in 
order that the remedies used may thoroughly permeate or soak into the 
parts. Cutting the hair closely, while not absolutely necessary, greatly 
facilitates treatment, and is always advised by all specialists in skin 
diseases. Depilation of the affected parts should be practised. Though 
troublesome, this is of great value in expediting the cure, as by the 
extraction of the hairs, the fungus within the hairs is removed, and the 
remedy has easier access to the follicles, and is thus brought into con- 
tact with the deep-lying fungus. The ointment or lotion chosen should 
be applied twice a day. Carbolic acid, one or two drams to the ounce 
of glycerine or ointment, is often satisfactory. The most useful rem- 
edy is a lotion of corrosive sublimate, two to five grains to the ounce. 
Oleate of mercury in the form of an ointment, ten to twenty-five per 
cent strength, may often be employed with good effect. Sulphur, 
citrine, tar, and ammoniated mercury ointments, either alone or sev- 
eral combined, are recommended by some writers. Chrysarobin, a 
dram to the ounce of collodion or gutta-percha solution, or in the form 
of a rubber plaster, forms an efficient application, and may be used 



762 Parasitic Diseases. 

when the disease is limited to well-defined patches. Occasionally, 
when the disease is rebellious, remedies such as will excite considerable 
inflammation in the affected part may be employed. Such remedies, 
however, are not without danger, and should be employed by the fam- 
ily physician under careful supervision. Croton oil, pure or diluted, 
with two or three parts of olive-oil, may be used for this purpose, the 
precaution being observed never to apply it over a large surface at a 
time. Several such applications may be necessary to produce inflam- 
mation sufficient to destroy the fungus. Acetic acid and cantharidal 
collodion may be similarly employed. Permanent baldness may follow 
the use of such active remedies, and their employment is to be recom- 
mended in rare instances only. After four or six weeks' treatment, 
all remedies should be suspended for a short time, in order that the 
exact conditions may again be carefully ascertained. Upon the dis- 
covery of scaliness, or broken hairs, or stumps, or the detection of the 
fungus by microscopic examination, treatment should be resumed, and 
so on until all traces of the disease have disappeared. Debilitated 
patients should take cod-liver oil. Wampole's cod-liver oil is very use- 
ful because of the iodine it contains. 

SCABIES. 

Definition. — Scabies, or itch, is a contagious disease of the skin, 
due to the invasion of an animal parasite, the Ascarus scabiei. The 
presence of the parasite within the cutaneous structure excites varying 
degrees of irritation, and in consequence the formation of vesicles and 
pustules, accompanied with more or less intense itching. The erup- 
tion is due to the invasion of the itch-mite, and is, therefore, to be 
found principally in the protected situations, or where the skin is thin 
and delicate, as between the fingers, on the wrists and forearms, in the 
folds of the axilla, on the abdomen, on the buttocks, about the genitals, 
and in the mammary region in the female. In infants and young 
children, especially in well-advanced cases, the scalp and face may also 
be involved. Scabies is a local disease, dependent solely upon the 
presence of the acarus. The prognosis is favorable. 

Diagnosis. — The diagnosis in uncomplicated cases is made with- 
out difficulty, the burrows, which are pathognomonic, may usually be 
found upon careful examination. They should be looked for espe- 
cially between the fingers and on the flexor surface of the wrists. But 
apart from the presence of the cuniculi, the distribution of the erup- 
tion is, as a rule, sufficiently characteristic. An eruption of multiform 
lesions occurring on the hands and wrists, on the flexor surface of the 
forearms, in the axillary folds, about the buttocks and genitals, and 
not unfrequently about the feet and toes, attended with more or less 
intense itching, and a progressive history, points unmistakably to 
scabies. It bears most resemblance to vesicular and pustular eczema, 
and to pediculosis ; but as in pediculosis the parasites live in the cloth- 
ing, necessarily only covered portions of the body show their irritating 



Parasitic Diseases. 763 

effects, and the hands, which are usually the first to be affected in itch, 
or scabies, and are usually most markedly involved, are entirely free 
in pediculosis. 

Treatment. — The disease is curable. As soon as the acari and 
their ova are destroyed, the itching and the secondary symptoms rapidly 
disappear. First, treatment should be preceded by a soap and hot- 
water bath. Sulphur soap is best for this purpose. Sulphur ointment 
should be freely applied after the bath. One dram of sulphur to one 
ounce each of lard and petrolatum, or half an ounce of each to one dram 
of sulphur. Naphthol, twenty to sixty grains to the ounce, has been 
highly recommended by Kaposi. Styrax is also a remedy of value, 
without the irritating effects of sulphur, and may be used in strength of 
one part to three parts of lard, or pure with two drams of alcohol and 
one dram of olive-oil to the ounce. In young children and in highly 
inflammatory cases, use the following: — 

li: Sulphur praecip 3j 

Balsam peruv 3j 

Adi pis lj 

M. et sig. 

Et must be thoroughly rubbed into the skin after each bath. The 
scalp and face, if involved, are to be treated the same as the body. 
Usually the ascari are readily killed in a few days. The underwear 
and bed linen are then to be changed. It is better and safer to change 
the bed linen after each bath, as the child can become reinfected from 
the unclean bedding. The following remedy has proven very effectual 
in the writer's hands in the permanent cure of itch: — 

I;*: Acid sulphuric , 3ij 

Spt. turpentine 3ij 

Flour of sulphur ...3iij 

Adi pis Jjss 

Mix the acid and turpentine together in a plate, and let it stand 
until effervescing ceases ; then add the sulphur and stir until it is thor- 
oughly mixed ; then add the lard. The patient must wash with warm 
water and sulphur soap, dry the affected parts, and put on plenty of the 
ointment ; if it seems to burn too much where the skin is very tender 
it may be diluted with a little lard. However, it must burn a little 
bit in order to kill the itch-mite. This should be well applied night 
and morning till all signs of the itch have disappeared. The bed linen 
should be changed daily till the patient is cured, also a fresh gown 
put on the patient every night. 

PEDICULOSIS. 

Definition. — Pediculosis, or lousiness, is a contagious affection, 
due to the presence of animal parasites. There are three varieties, 
named, according to location, pediculus pubis, pediculus capitis, and 
pediculus corporis. The pediculus capitis (head louse) is that usually 



764 Parasitic Diseases. 

observed in children ; pediculus corporis, or crab louse, lives in cloth- 
ing; pediculus pubis is rarely met with in children, seated upon the 
edges of the eyelids and upon the eyebrows. 

Diagnosis. — The diagnosis is readily made, as the pediculidse are 
usually to be found without difficulty. 

Treatment. — The treatment consists in the application of some 
remedy destructive to the pediculidse and their ova. Petroleum is one 
of the most effective remedies at command, one or two thorough appli- 
cations being usually sufficient. It may be mixed with equal parts 
of olive-oil to lessen the inflammability of the petroleum. Oil of sassa- 
fras one part and olive-oil four parts is a very effective remedy. Tinc- 
ture of cocculus indicus, pure or diluted, may also be applied with 
good results. On the following morning after the application of any 
one of the remedies, the whole scalp should be thoroughly cleansed 
with soap and hot water. Care must be taken not to allow the 
petroleum to run over the forehead or down the neck. In order to 
remove the nits from the hairs, acid or alkaline lotions may be 
employed, such as dilute acetic acid or vinegar, or solution of carbonate 
of sodium or borax. 

Pediculus corporis (crab-lice) live in the clothing, and are to be 
found chiefly in the folds and seams, and only exceptionally upon the 
skin. For their treatment the bedclothing is to be thoroughly baked 
or boiled, the pediculidse and ova being in this manner destroyed. 

Pediculus pubis is usually seen about the hairy parts of the 
genitals. 

Treatment. — Frequent washing and citrine ointment or amrao- 
niated mercury ointment, weakened with two to four parts of lard, may 
be carefully used. 



CHAPTEK LXI. 
POISONS AKD THEIR ANTIDOTES. 



WASPS. 

Bees, hornets, yellow-jackets, and other wasps produce painful 
stings. These stings rarely produce any trouble except painful swell- 
ing. In some rare instances a bee sting is fatal. 

Symptoms. — If general symptoms ensue, they appear rapidly, 
and consist of great prostration, vomiting, purging, and delirium or 
unconsciousness. These symptoms may disappear in a short time, or 
they may end in death from heart failure. Sting of the mouth may 
cause oedema of the glottis. 

Treatment. — To treat a bee sting, extract the sting if it be broken 
off, and apply locally a solution of washing-soda or bicarbonate of soda, 
tincture of arnica, spirits of camphor, iodine, or lead-water, and lau- 
danum. If necessary, stimulate with good whisky. 

OTHER INSECT BITES AND STINGS. 

The bite of a large spider is productive of inflammation, swell- 
ing, weakness, and even death. The tarantula is a much-dreaded 
spider. A scorpion has in its tail a sting, and a scorpion's sting pro- 
duces great prostration, delirium, vomiting, diaphoresis, vertigo, head- 
ache, local swelling and burning pain, followed often by suppuration, 
or even gangrene and fever. 

Treatment. — Tie a fillet about the bitten point ; make a crucial 
incision, favor bleeding, and swab .out the wound with pure carbolic 
acid or some caustic or antiseptic (if in the wilds, burn with fire or 
gunpowder) ; dress antiseptically, if possible, and stimulate as con- 
stitutional symptoms appear, slowly loosening the ligature. 

TARANTULA STING. 

Coal-oil is the antidote, provided it can be obtained immediately 
after the sting; apply locally. It will neutralize the poison, leaving 
no after-effects. 

SNAKE BITES. 

The poisonous snakes of America comprise the copperheads, water- 
moccasins, rattlesnakes, and vipers. There is also a poisonous lizard. 
The symptoms of snake bite are similar, whether it is the bite of an 
Indian cobra or of an American rattler, and they depend upon the 

(765) 



766 Poisons and Their Antidotes. 

dose of poison introduced. Poison injected into a vein may prove 
almost instantly fatal. In most varieties of snake the teeth lie along 
the back of the month, and are only erected when the reptile strikes. 
They are hollow, and the poison is deposited by contractions of the 
muscles of the poison-bag. 

Symptoms.- — The symptoms are pain, soon becoming intense; 
matted swelling of the bitten part, which swelling may be eaormous. 
and which is due to cedema and extravasation of blood, and which may 
assume a purpuric discoloration. There may be complete conscious- 
ness, or there may be lethargy, stupor, or coma. Some cases present 
spasms. The general symptoms are those of profound shock, which 
may present delirium. Death may arise from paralysis of the heart, 
and may occur in about five hours, but as a rule it is postponed for a 
number of hours. If death is deferred many hours, profound sepsis 
comes upon the scene, with glandular enlargement, suppuration, and 
sometimes gangrene. 

Treatment. — Cases of snake bite must, as a rule, be treated with- 
out proper appliances. In general, the rules are to twist several fillets 
of different levels above the bite, to excise the bitten area, to suck or 
cup the place bitten, if possible, and to cauterize it by a pure acid or by 
heat. An expedient among hunters is to cauterize by pouring gun- 
powder on the excised area and apply a spark, or by laying a hot ember 
on the wound. When a hot iron is available, use it. The fillets are 
not to be removed suddenly, and they had best be kept on for some 
time. Remove the highest constricting band first: if no symptoms 
come on after a time, remove the next, and so on ; if no symptoms 
appear, reapply the fillet. The constitutional treatment is expressed 
in one word, stimulate. Our only hope is in large doses of alcohol, and 
if they can be obtained, ammonia, ether, strychnine, or digitalis hvpo- 
dermically administered. Morphine may be given for pain. There 
is no specific for snake bite. Quick excision of the part bitten may 
often save the patient. 

ACIDS, ACETIC, HYDROCHLORIC, NITRIC, NITRO-MURIATIC, AND 

SULPHURIC. 

Treatment. — Give at once large draughts of water or milk, with 
chalk, whiting, magnesia, or baking soda; or strong soap-suds may be 
given to neutralize the acid; olive-oil, white of eggs beaten up with 
water, and later mucilaginous drinks of flaxseed tea or slippery elm 
are useful. If in much pain, twenty drops of laudanum may be given. 

CARBOLIC ACID, CREOSOTE, RESORCIN. 

Treatment. — Promote vomiting with warm drinks containing 
baking soda, saccharate of lime, and use the stomach-pump after such 
drinks have been taken ; or cause vomiting with mustard, a table- 
spoonful stirred to a cream with water. Give white of egg beaten up 



Poisons and Their Antidotes. 767 

with water or olive-oil — a cupful. Give stimulants, whisky, etc., 
freely, and apply warmth and friction to the extremities. 

ANTIMONY, COPPER, CROMIUM, IODINEA MERCURY, ZINC, WITH THEIR 

COMPOUNDS AND PREPARATIONS, CANTIIARIDES, COLCHICUM, 

ELATERIUM, AND CROTON, SAVIN, AND TANSY OILS. 

Treatment. — Give white of eggs (half dozen or more, raw) or 
flour mixed with water. Promote vomiting with water containing bak- 
ing soda, or cause it with mustard, a tablespoonful stirred to a cream 
with water, or use a stomach-pump. Give strong tea or coffee, stim- 
ulants if needed ; if in much pain, twenty drops of laudanum ; a demul- 
cent drink of flaxseed or slippery elm. 

CAUSTIC ALKALIES, POTASH, SODA, AMMONIA, ETC. 

Treatment. — Promote vomiting by large draughts of water. Give 
vinegar or diluted lemon juice, olive-oil, the whites of eggs beaten up 
with water, gruel, or demulcent drinks of flaxseed or slippery elm. 
Twenty drops of laudanum may be given if the patient is in much 
pain. 

ALCOHOL, BENZINE, BENZOL, CAMPHOR, CARBON BISULPHIDE, CHLORAL, 

CHLOROFORM, ETHER, HYDROCYANIC ACID, ITS COMPOUNDS 

AND PREPARATIONS. 

Treatment. — If necessary, an emetic of mustard, a tablespoonful 
stirred to a cream with water, must be given. Let the patient have 
plenty of fresh air, maintaining a horizontal position. Keep the body 
warm, and try to arouse the patient by ammonia to the nostrils, cold 
douche to the head, friction and mustard plasters to the limbs, etc. 
TTse artificial respiration. Strychnine for chloral and chloroform 
(l-30th grain) poisoning. 

CANNABIS INDICA, OPIUM, COCOA, THEIR ALKALOIDS, SALTS, AND PREP- 
ARATIONS. 

Treatment. — Give an emetic of mustard as above, followed by 
large draughts of warm water, then drink strong tea or coffee. Give 
rectal injections of capsicum. Arouse the patient, keeping him awake 
and in motion; use artificial respiration even after life seems extinct. 
In case of opium poisoning, atropine or tincture of belladonna is the 
antidote. 

ACONITE, DIGITALIS, LOBELIA, TOBACCO, VERATRUM VIRIDE, THEIR 
ALKALOIDS, SALTS, AND PREPARATIONS. 

Treatment. — Give an emetic of mustard as above, followed by 
large draughts of warm water ; give strong tea or coffee, with powdered 
charcoal, stimulants, whisky, etc., freely; apply warmth to the extrem- 
ities. Keep the patient in a horizontal position, and use artificial 
respiration persistently. 



768 Poisons and Their Antidotes. 

BELLADONNA, CALABAR BEAN, CONIUM, GELSEMIUM, HYOSCAMUS, SAN- 
TONIN, STRAMONIUM, THEIR ALKALOIDS, SALTS, AND 
PREPARATIONS. 

Treatment. — Give emetics of mustard, followed by large draughts 
of warm water; give strong tea or coffee with powdered charcoal; 
stimulants, whisky, etc., if necessary. Arouse the patient, if drowsy; 
apply heat and friction to the extremities; use artificial respiration. 

COCCULUS INDICUS, NUX VOMICA, THEIR ALKALOIDS, SALTS, AND 

PREPARATIONS. 

Treatment. — Give emetics of mustard, — a tablespoonful stirred 
to a cream with water, — followed by large draughts of warm water. 
Give powdered charcoal, iodide of starch, or tannin. To relieve 
spasms, give chloral hydrate — twenty-five grains — in half a teacup of 
water, or potassium bromide, or inhale pure chloroform. The chloral 
hydrate may be injected into the rectum if it can not be given by the 
mouth. 

ARSENIC AND ITS COMPOUNDS, COBALT, PARIS GREEN, ^ROUGH ON 

rats/' ETC. 

Treatment. — Promote vomiting with warm water, or use stomach- 
pump, or mustard, as above. Procure at once from a drug store 
hydrated oxide of iron, and give a teacupf ul of it ; or mix a teaspoon- 
f ul of calcined magnesia with a cup of water ; add three tablespoonfuls 
of tincture of iron, mix well, and give all of it. Follow with olive-oil 
or white of eggs, raw, and mucilaginous drinks. Twenty drops of 
laudanum may be given if there is much pain. 

OXALIC ACID. 

Treatment. — Give chalk or whiting, a tablespoonful, or even air- 
slaked lime, a teaspoonful, in fine powder mixed with two tablespoon- 
fuls of vinegar. Do not give soda or potash to neutralize the acid. 
Promote vomiting by large draughts of water, or with mustard, a 
tablespoonful stirred to a cream with water. Give olive-oil and 
mucilaginous drinks, stimulants, whisky, etc., and apply warmth ~o 
extremities. 

BARIUM AND ITS SALTS, LEAD AND ITS SALTS. 

Treatment. — Give Epsom salts, one-half ounce, or Glauber's salts, 
one ounce, dissolved in a tumbler of water. Promote vomiting with 
warm mustard water, a tablespoonful of mustard stirred to a cream 
with water. Give milk, demulcent drinks of flaxseed tea or slippery 
elm, and laudanum, twenty drops, if there is much pain. 

SILVER NITRATE ( LUNAR CAUSTIC ). 

Treatment. — Give common salt, a tablespoonful dissolved in a 
tumbler of warm water ; then an emetic of mustard as above, followed 



Poisons and Their Antidotes. 769 

by large draughts of warm water. Later, arrowroot gruel or demul- 
cent drinks of flaxseed or slippery elm may be given. 

PHOSPHOEUS COMPOUNDS (EAT PASTE). 

Treatment. — Give an emetic of mustard, — a tablespoonful stirred 
to a cream with water — or, better still, an emetic of blue vitriol, three 
grains every five minutes until vomiting occurs. Give a teaspoonful 
of old, thick oil of turpentine; also Epsom salts, one-half ounce in a 
tumblerful of water. Do not give oil, except the turpentine. 

DOMESTIC EEMEDIES THAT SHOULD BE KEPT ON HAND IN EVEEY 

HOUSEHOLD. 

Castor-oil, Castoria, sweet-oil, glycerine, vaseline, linseed-oil, tur- 
pentine, improved compound cathartic pills, Epsom or Rochelle salts, 
triturate of calomel and soda (one-fourth grain Wyeth's or Parke- 
Davis'), quinine, spirits of camphor, good rye whisky (for emergencies 
in case of snake bite or heart failure), tincture of ginger or ginger root, 
paregoric, laudanum (properly labeled), syrup squills, boracic acid 
(properly labeled), chlorate of potash, bicarbonate of soda, flaxseed 
meal (to be kept in a closed vessel), mustard, hot-water bag, and foun- 
tain syringe. 



i 



49 



CHAPTER LXII. 
FRACTURES. 

Definition. — A fracture is a solution, by sudden force, of conti- 
nuity in a bone or of a cartilage. A simple fracture is when the bone 
only is divided. A compound fracture is a division of the bone with 
a wound of the integuments communicating with the bone — the bone, 
indeed, generally protruding. In a comminuted fracture the bone is 
broken into several pieces, and in a complicated fracture there is, in 
addition to the injury done to the bone, a lesion of some considerable 
blood-vessel or nerve trunk. Fractures are also termed transverse or 
oblique, according to their direction. 

The treatment of fractures consists, in general, in reducing the 
fragments when displaced, maintaining them when reduced, prevent- 
ing the symptoms which may be likely to arise, and combating them 
when they occur. The reduction of fractures must be effected by 
extension, counter-extension, and coaptation. The parts are kept in 
apposition by position, rest, and an appropriate apparatus. The posi- 
tion must vary according to the kind of fracture. Commonly, the frac- 
tured limb is placed on a horizontal or slightly inclined plane, in a state 
of extension, or rather in a middle state between extension and flexion, 
according to the case. 

CAUSES OF FRACTURES. 

The causes of fracture are exciting, immediate or direct, and pre- 
disposing or indirect. 

Exciting Causes. — These are external violence and muscular 
action. 

Immediate Causes. — Direct violence acts upon the bone at the 
point where it breaks ; a blow, the passage of a wheel over the limb, any 
crushing force, is an instance of this kind. Indirect violence is trans- 
mitted through some length of the bony structure, as when the clavicle 
is broken by a fall on the palm of the hand. Here the mechanism is 
often plainly leverage, and sometimes a twist also is impressed upon the 
bone. Muscular action, if sudden and excessive, as in cases of convul- 
sions, may cause fracture. 

Predisposing Causes. — Hereditary fragility is a condition com- 
monest among women, it often existing for generation after generation, 
and in this condition fractures occur from an infinitely slight force. 
There are some children who seem to have an especial liability to 
fractures. Their bones are brittle, and give way to very slight forces. 
(770) 



Fractures. 771 

Certain constitutional disorders have been assigned in some of these 
cases. Syphilis has been regarded as a cause of fragility of the bones. 
Sometimes there is no assignable cause, the brittleness seeming to be a 
peculiarity of structure of the bones. Collins 1 and Graham 2 have 
reported cases of this kind. 

Rickets predisposes to fracture because of altered bone structure 
and the great liability to falls. 

Atrophy of bone, as has been seen in old people, is a condition nor- 
mal in senility. It may arise from want of use, as is observed in the 
bed-fast, in the wasted femur of hip-joint disease, and in the bones of a 
stump. It may arise from pressure, as when an aneurism compresses 
the ribs, sternum, or vertebrae. 

Among other pathological and predisposing causes are to be men- 
tioned cancer, sarcoma, and hydatid cysts of bones, caries, necrosis, gout, 
scrofula, and scurvy. 

Symptoms of Fracture. — The history of an injury is to be con- 
sidered. In spontaneous fracture there may be no record of violence ; 
for instance, when a bone breaks while turning in bed. In investigating 
the history, not only seek for violence, but determine exactly how the 
accident happened. 

A sound of crepitus, of the grating sensation caused by rubbing 
the ends of the broken bones together, is a most valuable sign of fracture, 
and when detected during the examination of a limb supposed to be 
fractured, the diagnosis is made'clear. The patient may have heard the 
cracking sound. A rupture of a tendon or a ligament produces a similar 
sound. 

Pain is usually, but not invariably, present (absent often in 
rickets). Malgaigne says that "in some fractures the pain is slight or 
absent, in others it is torturing, and in most it is severe for a time 
after the injury but gradually abates unless reinduced by movement. 
Pain developed at the time of the accident is far less important as a 
symptom than that which can subsequently be produced by movement. 
In direct fractures there is an area of pain at the point of applica- 
tion of the force, and another at the seat of fracture. Pain at the seat 
of fracture can be aggravated infinitely by pressure or movement, and 
is rather narrowly localized." 

Bryant's Diagnosis of Fractures. — "The diagnosis of fractures is 
usually easy, though in exceptional cases it is difficult, if not impossible. 
It is easy when, after a blow or fall attended by the sensation of some- 
thing giving way, deformity is found, with inability to move the limb, 
and on manipulation abnormal mobility of the injured limb exists, with 
crepitus from rubbing of the broken fragments together; when pain 
attends any attempt at movement, and swelling rapidly follows the 
accident; and when shortening exists, which is remedied by extension. 

l British Medical Journal, May 13, 1882. 

2 Boston Medical and Surgical Journal, May 15, 1884. 



772 Fractures. 

The diagnosis is difficult when, as in impacted fractures, abnormal 
mobility and crepitus are absent, and only slight but fixed deformity 
exists; when local pain and shortening are the only symptoms, and 
the nature of the accident is the only guide; when a transverse frac- 
ture of such a bone as the tibia exists without displacement and with 
no fracture of the fibula; when the fracture is into, or in the neigh- 
borhood of, a joint, and there is much swelling of the injured part, 
and when a fracture and a dislocation coexist." 

When a bone is broken near a joint, and effusion into it follows the 
injury, the surgeon should suspect the presence of a fissure of the bone 
into the articulation ; and when a V-shaped fracture of the lower third 
of the tibia is present, the V occupying the internal or subcutaneous 
surface of the bone, and not the crest, this complication is to be looked 
for. 

When a fracture is transverse, there may be no, or only some slight, 
lateral displacement ; when oblique, there will probably be some shorten- 
ing of the limb from the drawing up of the lower portion of the limb, or 
riding, as it is called, of one end over the other. At times there will be a 
rotation of the limb, and in comminuted fractures separation of the ends 
of the bone. These points will be greatly determined by the character 
of the fracture, the bone that is involved, and the amount of muscular 
action that influences the fracture. 

In parallel and conjoined bones, of which only one is broken, the 
deformity that exists is likely to be less marked than where a single bone 
is broken ; for under these circumstances the non-fractured bone tends to 
neutralize the action of the muscles through which deformity or con- 
traction usually takes pla.ce. Muscular action is undoubtedly the main 
cause of deformity, tonic action of the muscles existing under all cir- 
cumstances, and spasmodic action when the muscles are irritated by 
fragments and attempts at reduction. 

Muscular spasms being the main cause of deformity and shortening 
of the limb after fracture, it becomes an important point to recollect 
in treatment that the peculiar deformity associated with any special 
form of fracture can be obviated by neutralizing the action of the 
muscles that produce it. 

When a bone is fissured, and not displaced, the periosteum not 
being divided, there will be but little displacement ; in children this con- 
dition is often found. 

Crepitus is a most valuable sign of fracture. The crepitus of effu- 
sion of tendons must not be mistaken for that of a broken bone. It is a 
soft crepitus rather than a hard one, as in bone. Bursal crepitation is 
particularly liable to mislead. 

When some swelling follows immediately upon the accident, it 
means a ruptured blood-vessel, arterial or venous. When it occurs 
within a few hours, it is due to inflammatory effusion. 

In all cases of supposed displacement, the normal condition of the 
limb must be inquired into, and the sound one compared with the 



Fractures. 773 

affected one; for an old acquired deformity in a limb has been mis- 
taken for one caused by an accident, and attempts have been made to 
restore — or, rather, to reduce — the parts to their supposed normal 
condition. 

Treatment. — The principles of the treatment of fractures are very 
simple, though the practise is often very difficult. To restore a bone to 
its normal position and to keep it there by means of surgical appliances, 
or, as John Hunter expressed it in 1787, "to place the parts in a proper 
position by art — that is, as near their natural position as possible — and 
keep them so," are simply rules to be observed, but to carry them out 
often demands the highest surgical skill and ingenuity; and yet the 
whole treatment of fractures is really comprised in these two indi- 
cations. 

In examining a fracture the greatest care is requisite, and only 
sufficient manipulation should be allowed to ascertain the seat of the 
fracture, the line of its direction, and the tendency a fragment may have 
to ride in any direction, this special tendency being the one point to be 
remembered in the treatment. The points, moreover, should be made 
out at the single examination prior to treatment; for repeated exam- 
inations, whether by the responsible surgeon or by his assistant, are 
to be condemned, as they can only do mischief by exciting more local 
irritation and adding to the injury which the muscles and soft parts 
have already sustained. For this reason, when, after an accident a frac- 
ture is suspected to have taken place, the surgeon or bystander should do 
no more than bind the limb to some immovable apparatus, such as a 
wisp of straw, a bundle of sticks, or two pieces of wood fixed by a hand- 
kerchief till the sufferer has been carried home and placed in the 
position in which he is to be treated. When the lower extremity is the 
affected part, the injured limb may be bound to the sound one, the 
latter acting as a splint. 

In compound fracture the same precautions are necessary. Bleed- 
ing should be arrested by the application over the wound of a pad, or 
bandage, kept in position by means of pressure and the elevation of the 
limb, while in more severe cases the tourniquet or some local pressure 
over the main artery may be called for. 

When a patient is placed in bed where he is to be treated, the 
fracture ought to be manipulated, and its position, nature, and peculiar 
tendency made out ; and when made out, it is to be "set," or put up at 
once. The only exception to this rule is when time has been allowed to 
pass before treatment is commenced, and much oedema, or swelling of the 
injured extremity exists ; then it is better to fix the injured limb raised 
upon a pillow with a long sand-bag on either side to act as a splint, and 
possibly a third around the foot, the pillow and side sand-bags being 
firmly bound together by a strip of bandage, the whole forming an 
immovable apparatus, and letting it remain for the first month or five 
weeks till the limb could be put up in some starch or an immovable 
apparatus, and the patient allowed to get up. 



774 Fractures. 

In "setting" a fracture some care is needed, and the opposite and 
corresponding limb should always be before the surgeon as a guide. In 
extending a broken limb to restore the bones to their normal position, 
the upper portion should be firmly held by an assistant, to make counter- 
extension, and the muscles attached to it are relaxed by placing the limb 
in a slightly flexed position; a second assistant or the surgeon may 
then extend the fractured end, while the latter gently manipulates the 
fracture to make out its points. The extension should be steady, free 
from all jerks and violent movements, gentle lateral, rotary, or other 
movements being given as required to restore the displaced position of 
bone, the pressure of the thumb or finger being freely used to bring 
about an accurate coaptation, or setting of the fragments, for the surgeon 
must remember that muscular contraction is better overcome by con- 
tinued extension than by temporary force, and that for the treatment of 
fractures generally, moderate extension continuously applied is prefer- 
able to forcible extension in any of its forms. The inhalation of chloro- 
form at times is a valuable aid in the reduction of a fracture. If, when 
the fractured bones have been reduced, muscular spasms are so severe 
as to render it impossible to keep them in situ — a condition which is not 
uncommon in fractures of the leg — the tendon of the offending muscle 
may be divided. In otherwise intractable fracture of the leg there is no 
operation of greater value and attended with less evil than the division 
of the tendo Achillis. In a general way, however, the muscular spasms 
cease after the first three or four days. (Bryant.) 

When the fracture has been reduced and by manipulation coap- 
tated, or "set," splints or other mechanical appliances are necessary to 
keep the bones in their normal position, and the simpler these appliances 
are, the better, so long as they fulfil their purpose. These splints should 
always be well padded, and the pads so adjusted as to fit into the inequal- 
ities of the limb and protect it from any local pressure. They should 
be firmly and immovably fixed to protect the limb by inelastic straps or 
bandages, and the seat of fracture, as a rule, should be left exposed for 
the surgeon's examination, in order that the fracture may be readjusted 
if displacement takes place. To cover up a broken bone by bandages 
or splints is a mistake. The position of the bone during the progress of 
repair should always be open to view, the former practise being based on 
hope, the latter on certainty. Pott's rule, that the splints include the 
joint above as well as below the fracture, is sound, though, it is said, 
it can not always be followed. Every joint, however, should be fixed 
when by its action the broken bone is rendered movable. 

When one bone is broken in a limb where double bones exist, the 
second acts as a splint and keeps up extension. Under these circum- 
stances a simpler apparatus is required to keep the fractured bone quiet 
and retain the action of the muscles that move, than under other cir- 
cumstances. 






Fractures. 775 

Extension is a valuable and necessary adjunct to other treatment, 
and should be kept up by means of weights, pulleys, or such other 
appliances as the ingenuity of the surgeon may suggest. 

After the setting of the fracture, the essential point to be observed 
in its treatment is the immobility of the broken bone ; and next to this, 
its exposure to observation during the progress of repair, to render cer- 
tain that the bone has maintained its right position. 

Treatment of Compound Fracture. — The treatment of compound 
is similar to that of simple fractures, plus the treatment of the wound, 
with its complications and the broken fragments or projecting portions 
of bone; but "rest" of the bone is the great object we have to aim at. 

The fractures should be "set" in the same way as the simple, great 
care being observed in the manipulation that the soft parts are not more 
injured. Loose fragments of broken bone must be taken away, pro- 
jecting portions excised, and the bone reduced, the wound being enlarged 
when necessary to facilitate this act. The injured parts, too, ought to 
be thoroughly cleansed and all wounded vessels twisted or ligated; 
the bones should then be fixed immovably by means of splints, inter- 
rupted splints often being required. 

When the wound is not very extensive, it should be sealed by means 
of a piece of lint saturated with blood, or, what is better, with the 
compound tincture of benzoin. If the carbolic-acid dressing is 
employed, the wound should be well washed with a weak solution of one 
part in a hundred of sterilized water and dressed under the spray. The 
wound should be interfered with as little as possible, since now, as when 
the following words were uttered, "the great mischief and bad success 
arising in the treatment of compound fractures is the dressing them 
every day and applying fresh poultices, which necessarily moves the ends 
of the bones. The limb, if possible, should never be moved. When the 
soft parts are much crushed and the large vessels and nerves injured, 
amputation may be called for, more particularly in old subjects." 

FRACTURE OF THE CEAVICLE. 

"The causes of clavicle fractures are direct violence, indirect vio- 
lence, and, very rarely, the contractions of the deltoid and clavicular 
fibers of the great pectoral muscle." 

Symptoms. — In fractures of the shaft, the attitude of the patient 
is peculiar. The patient supports the elbow or wrist of the injured side 
with the hand of the sound side and also pulls the extremity against 
the chest ; the head is turned down towards the shoulder of the damaged 
side as if trying to listen to something in the joint, thus relaxing the pull 
of the sterno-cleido-mastoid muscle upon the inner fragment. The 
shoulder is nearer the sternum on a lower level, and farther front than 
that of the sound side. Loss of function is shown by inability to abduct 
the arm. Considerable pain exists, which is increased by motion, by 
pressure, and by the extremity hanging down without support. 



776 Fractures. 

Treatment. — In treating fracture of the shaft, reduce the fracture 
as soon as possible by throwing the shoulder upward, outward, and 
backward. If the patient is a girl, it is desirable to minimize the 
deformity. Place her in the recumbent position on her back on a 
hard bed, with a small pillow under her head, a firm and narrow 
cushion between the shoulders, a bag of shot resting over the seat 
of fracture, and the forearm lying on the front of the chest, the 
arm being held to the side by a sand-bag. The recumbent posi- 
tion may be maintained for about three weeks, till union has fairly 
taken place, but men and children will rarely be found willing to fol- 
low such a line of treatment; and, happily, it is not required, for 
nearly, if not quite, equally good results will be secured by imitating 
what takes place on the assuming of the recumbent position, viz., by 
fixing the lower blade of the scapula to the chest, binding down its 
angle to the thorax, and preventing the tilting forward and rotation 
of the bone through which the deformity takes place. In a child 
with an incomplete fracture, a handkerchief sling for the forearm r 
worn three weeks, is all that is needed. 

In complete fracture, the Velpean bandage is efficient. Before ap- 
plying it, place lint around the chest and cotton over the elbow. Change 
the bandage every day for the first week, and after that period, every 
third day. Each time it is changed, rub the skin with alcohol, ethe- 
real soap or soap liniment; then dry it, and examine for excoriations, 
which, if any are found, are to be anointed with zinc ointment before 
the dressing is reapplied. The dressing is permanently removed at 
the end of four weeks, the arm being worn in a sling for another week- 

FRACTURES OF THE UPPER EXTREMITY. 

These include fracture of the anatomical neck of the humerus,, 
fracture of the surgical neck, and fracture of the head, oblique and 
longitudinal. 

Symptoms. — The symptoms in fracture of the anatomical neck 
are pain, swelling, ecchymosis, slight irregularity of the shoulder, and 
inability to abduct the arm voluntarily. Deformity, as a rule, is 
slight or is absent, because the capsule is rarely entirely torn from 
the lower fragment. Cases of this kind, though rare, do occur, espe- 
cially in the aged. 

Treatment, — The nature of the accident having been ascertained, 
and the question of impaction decided, the treatment becomes simple. 
In a non-impacted fracture the first aim is to bring the bones into as 
good apposition as possible, and to keep them there by means of splints 
and position. Flex the arm to a right angle with the body, and carry 
up from the base of the fingers to above the elbow the turns of a 
spiral reverse bandage. Interpose lint between the arm and the side, 
and place a folded towel or a small pad in the axilla, tying the tapes 
over the opposite shoulder. Mould a shoulder cap upon the outer 
aspect of the arm and upon the shoulder. This cap, which is made 




Plate e.—Jf-S, DesauWs Bandage: i, First Boiler; 2, Second Boiler; 3, Third Boiler; 
4, Velpeau's Bandage; 5, Figure-of-8 Bandage of the Breast; 6, Spiea of the Shoulder. 




Fractures. Ill 

of pasteboard or of felt, should reach below the insertion of the 

deltoid muscle, covering one-half the circumference of the arm, and 

is to be padded with cotton. The arm with 

the shoulder-cap is fixed to the side by the 

second roller (of Desault, two and a half 

inches wide and seven yards long), and the 

hand is hung in a sling. The endges of the 

bandage had best be stitched. The apparatus 

is changed daily for the first few days, the Fi 9- 32.— Shoulder Cap. 

body and arm being rubbed at each change 

with alcohol, soap liniment, or ethereal soap. After this period, 

a change every third or fourth day is often enough. Passive 

motion is started at the end of four weeks, and the dressings are 

removed at the end of six weeks. In impacted fracture do not pull 

apart the impaction, but apply a cap to the shoulder, and fix the arm 

to the side for five weeks. ^To pad is used. The fracture unites in 

deformity. ( Bryant . ) 

FRACTURES OF THE SURGICAL NECK OF THE HUMERUS. 

The surgical neck is the constricted portion of bone between the 
tuberosities and the upper line of the insertion of the muscles on the 
bicipital groove. Fractures in this region are usually transverse, but 
they may be oblique. The causes are almost always direct force. 

Symptoms. — Pain running into the fingers from pressure upon 
the brachial plexus ; crepitus and mobility on extension ; and flatten- 
ing, which differs from the flattening of dislocation, in that it occurs 
farther below the acromion, and that this process is not so prominent. 
Shortening to the extent of an inch is noted. The lower fragment 
is drawn inwards towards the chest, while the upper fragment is 
drawn upwards and outward by the muscles that are inserted into 
the tuberosities. The bone projects forward or backward, according 
to the direction of the fracture. The more oblique the line of frac- 
ture, the greater the deformity. 

Treatment. — The same treatment is applicable in fracture of the 
surgical neck of the humerus as in fracture of the anatomical neck. 
The aim should be to keep the impacted bones in position, and to 
prevent their being loosened, so that natural processes may effect 
a cure in a month or six weeks, with a limited degree of deformity. 

FRACTURES OF THE SHAFT OF THE HUMERUS. 

These are common, and more readily made out, as well as more 
successfully treated, than any other fracture. When oblique, they 
are frequently followed by some degree of shortening. When the 
fracture is transverse, there is no displacement. Loss of power in the 
arm, mobility of the bone, crepitus, local pain, and deformity, are 
ample symptoms to indicate the accident. 



778 Fractures. 

Treatment. — In the primary treatment of all fractures of the 
arm, it is a wise and scientific practise to keep the forearm at rest, 
which is best done by the application of some angular splint extending 
from the shoulder or axilla to the wrist, associating with it a pos- 
terior or anterior short splint, reaching from the shoulder to the 
elbow. After about two or three weeks, the angular splint may be 
removed, and some immovable one applied, the forearm being left 
free. 

Any splints that secure immobility of the broken bone after its 
ends have been coaptated by manipulation, must be regarded as bene- 
^ ficial, and no splints can do this effectually that allow freedom of 
movement of the forearm. When two lateral splints appear the better 
adapted to keep the bones in position, they must be angular, to include 
the elbow, and bent at a right angle. Splints are to be worn six 
weeks. Passive movements are not to be made until the fracture is 
well united (after six weeks) ; for if made too soon, they predispose 
to non-union, and as no joint is involved, ankylosis will not occur. 

FRACTURE OF THE SHAFT OF THE ULNA. 

This is most apt to be near the middle, and is always due to 
direct violence. In these cases there is, as a rule, little displacement, 
and when it exists, it is of the lower fragment. On manipulation, 
crepitus is usually present, with local pain. Fracture of the Olecranon 
process is a very frequent accident from a fall or blow upon the elbow, 
or a sudden action of the triceps. In fracture of the shaft of the 
ulna, the long axis of the hand is not in a line with the long axis of 
the forearm, but is internal to it. The forearm at and below the seat 
of fracture is narrower and thicker than normal. 

Treatment. — In treating fracture of the shaft, place the forearm 
midway between pronation and supination, so as to bring the frag- 
ments together, and to obtain the widest possible interosseous space. 
This limits the danger of ankylosis in this space. The surgeon has 
only to see that the broken bone is kept quiet by means of two well- 
padded, straight splints, one long enough to reach from the inner con- 
dyle to below the fingers, the other from the outer condyle to below the 
wrist; place a long pad over the interosseous space on the flexor side 
of the limb, and another on the extensor side ; apply the splints, and 
hang the arm in a triangular sling (Fig. 1, plate f). Passive motion 
is to be made in the third week, and the splints are to be worn for 
four weeks. 

FRACTURE OF THE SHAFT OF THE RADIUS. 

In all fractures of the radius it is essential to keep the hand at 
rest, and as a consequence, all splints should, at the least, extend 
down to the base of the fingers. 

Symptoms. — The upper fragment is drawn forward by the biceps, 
and is fully supinated by the supinator-brevis muscle. The lower 



Fractures. 779 

fragment is fully pronated by the pronator-quadratus and pronator- 
radii-teres muscles, and its upper end is pulled into the interosseous 
space. There are crepitus, mobility, pain, narrowing and thickening 
of the forearm below the seat of fracture, and loss of the power of 
pronation and supination. The head of the bone is motionless during 
these movements, and the hand is prone. 

Treatment. — In treating this fracture, Da Costa's advice is: 
"'Do not put the forearm midway between pronation and supination, 
as this position will not bring the fragments into contact, the upper 
fragment remaining flexed and supinated. To bring the lower frag- 
ment in contact with the upper, flex, and fully supinate the forearm. 
Put the arm upon an anterior angular splint for four weeks (Fig. 3, 
plate f), and make passive motion in the third week. 

"In treating fractures below pronator radii teres, the forearm is 
flexed, and is placed midway between pronation and supination ; 
interosseous pads and two straight splints are applied as for fracture 
of the ulna. The splints are worn for four weeks, and passive motion 
is made in the third week." 

FRACTURE OF THE SHAFTS OF BOTH BONES OF THE FOREARM. 

This is not frequently seen. It is caused by direct or indirect 
force. 

Symptoms. — In fracture of both bones of the forearm, the hand 
is pronated, and the two lower fragments come together and are 
drawn upwards and backwards or upward and forward by the com- 
bined force of flexor and extensor muscles, shortening being manifest, 
and a projection being detected on either the dorsal or the flexor sur- 
face of the forearm. 

Treatment. — Bryant states that under all circumstances the fore- 
arm should be flexed, and the hand kept in the semi-prone position. 
Two wide splints should be employed, well padded, broad, and coming 
down to the roots of the fingers, the surgeon, so arranging his pads as 
to prevent deformity and to neutralize the peculiar tendency of the 
fracture. When the parts are bandaged too tightly, the bones may 
be pressed together, and consolidation takes place as a whole, with 
consequent loss of motion, or the two bones may be braced together 
Dy some bony isthmus. Under all circumstances the fracture should 
be put up with the hand supinated, the dorsal splint being first ap- 
plied, and then the palmar, the forearm being semiflexed. When frac- 
ture of the radius and ulna takes place above the wrist joint, the symp- 
toms may simulate those of dislocation ; but the greater mobility of the 
lower ends of the bones, crepitus, and local pain ought to forbid the 
error being acted upon. 

FRACTURES OF THE CARPAL AND METACARPAL BONES. 

Fractures of this kind can occur only from direct violence, some 
crushing force being the usual form. One or more bones may be 
broken. The first metacarpal bone is oftenest broken. 



780 Fractures. 

Symptoms. — The signs of a metacarpal fracture are dorsal pro- 
jection of the upper end of the lower fragment, the head of the bone 
being felt in the palm, with pain, crepitus, and often evidences of 
direct violence. 

Treatment. — The treatment for a fracture of the carpal bones 
should be such as will serve for all ; for the application of an anterior 
splint, as well as cold lotions and absolute rest of the injured part, 
ought always to be observed in all clear cases, as also in those that 
are doubtful, and with these a good result may generally be secured. 
All splints must be well padded. 

To treat a fracture of the metacarpal bones, reduce by extension ; 
* place a large ball of oakum, cotton, or lint in the palm to maintain 
the natural rotundity, and apply a straight palmar 
GT) splint, well padded (see Fig. 33), like that used in 

p. ss ^ the fracture of the carpus. It may be necessary to 
apply a compress over the dorsal projection. The 
duration of treatment is three weeks, and passive motion is begun 
after two weeks. 

Many compound comminuted fractures of the carpus require 
amputation. In an ordinary compound fracture, ascepticize, drain, 
dress with antiseptic gauze and a plaster-of -Paris bandage, cutting 
trap-doors in the plaster over the ends of the drainage-tube. In a 
simple fracture, use lead-water and laudanum for a few days. 

Symptoms and Cause of Fracture of the Phalanges. — The pha- 
langes are often broken. The fracture may be compound. The cause 
usually is direct force. The fracture is characterized by pain, bruis- 
ing, crepitus, and mobility, with very little or no displacement, 

Treatment. — If the middle or distal phalanx is broken, mould on 
a trough-like splint of pasteboard or gutta-percha, which splint need 
not run into the palm. If the proximal phalanx is broken, run the 
splint into the palm of the hand. Make the splint of gutta-percha, 
pasteboard, wood, or leather. The splint is worn three weeks. A 
sling must be worn to prevent the finger from being knocked and 
hurt. Some cases require a dorsal as well as a palmar splint. 

FRACTURE OF THE FEMUR. 

This is a very common injury. The divisions of the femur are: 
First, the upper extremity; second, the shaft, and, third, the lower 
extremity. 

When the fracture involves the neck near the head of the bone, it 
is called intracapsular ; when the base of the neck near the trochanters, 
extracapsular; but in these the joint is generally involved, the line of 
fracture, as a rule, being oblique from the neck within to the base of 
the neck without the capsule. Both forms may be impacted. The 
former is so frequently ; the latter, generally. 

In the fracture of the neck near the head of the bone, the neck 
of the bone is usually driven into the head. In the fracture of the 
base of the neck, the neck is, as a rule, driven into the shaft. 



K 




Plate f. — 1, Bond's Splint in Chile's Fracture; 2, Tioo Straight Splints in Fractures of 
Both Bones of the Forearm: 3, Anterior Angular Splint in Fractures in or near the Elbow- 
joint; 4< Internal Angular Splint and Shoulder-cap in Fracture of the Surgical Neck of the 
Humerus; 5, Internal Angular Splint in Fracture of the Shaft of the Humerus; 6, Frac- 
ture-box in Fractures of the Bones of the Leg, 



Fractures. 781 

Fractures of the narrow part of the neck of the femur are gen- 
erally caused by indirect violence, such as tripping in the carpet ; 
fracture of the base of the neck, by direct violence, such as a fall upon 
the trochanter. When the posterior ridge of bone penetrates the 
•trochanter, there will be eversion of the foot, the outer surface of 
rhe trochanter looking backward, and the anterior surface of the neck 
will be felt as a prominent projection beneath the rectus muscle. When 
the anterior ridge of bone penetrates the lower fragment, the foot 
will be straight or inverted, the surface of the trochanter will look 
outward, and a great fulness will be felt behind the trochanter. 
Should the limb be much adducted when the patient falls upon the 
trochanter, the lower border of the neck may be driven into the 
trochanter; and should the limb be much abducted when the fall takes 
place, the fracture will probably be in the narrower part of the neck, 
and therefore unimpacted and intracapsular. When the penetration 
of the neck is great, the trochanter will be broken off, and there will 
be no impaction, but the usual unimpacted fracture of the neck. 
(Bryant.) 

SYMPTOMS OF INTRACAPSULAR FRACTURE OF THE FEMUR. 

There is usually shortening to the extent of from half an inch to 
an inch. Shortening of a quarter of an inch does not count in diag- 
nosis, for, as Hunt shows, one limb is often naturally a little shorter 
than the other. If the reflected portion of the capsule is not torn, 
the shortening is trivial in amount or is entirely absent. In some 
cases shortening gradually or suddenly increases some little time after 
the accident. This is due to separation of an impaction, tearing of 
the previously unlaeerated capsular reflection, restoration of muscular 
strength after a paresis, or absorption of the head of the bone. Short- 
ening is due chiefly to pulling up of the lower fragments by the ham- 
strings, the glutei, and the rectus muscles. 

Eversion exists, spoken of as "helpless eversion," though in a 
very few instances the patient can still invert the leg. This eversion 
is due to the force of gravity, the limb rolling outward because the 
line of gravity has moved externally. That eversion is not due to the 
action of the external rotator muscles, as was taught by Astley Cooper, 
is proved by the fact that when a fracture happens in the shaft below 
the insertion of these muscles, the lower fragment still rotates out- 
wards. In some unusual cases inversion attends the fracture. Be- 
sides shortening and eversion, the leg is somewhat flexed on the thigh, 
and the thigh on the pelvis, the extremity, when rolled out, resting 
upon its outer surface. Loss of power is a prominent symptom. The 
limb can rarely be raised or inverted. Pain is trivial except upon 
motion, when it can be localized in the joint. Crepitus often can not 
be found, either because the fragments can not be approximated or 
because they are greatly softened by fatty change. To obtain crepitus 
the front of the joint must be examined while the limb is extended and 



782 



Fractures. 



rotated inward. The diagnosis is readily made without it. In many 
cases it can not be found, and the endeavor to obtain it inflicts pain, 
and may effect damage. These fractures offer a not very flattering 
chance of repair, and efforts to find crepitus may injure the capsule 
or pull apart an impaction. (Allis.) 

The altered arc of rotation of the great trochanter is Desault's 
sign. The pivot on which the great trochanter revolves is no longer 
the acetabulum, and the great trochanter no longer describes the seg- 
ment of a circle, but it rotates only as the apex of the femur, which 
rotates around its own axis. 

Relaxation of the fascia lata (Allis' sign) simply means shorten- 
ing. The fascia lata (the ilio-tibial band) is attached to the ilium 
and the tibia, and when shortening brings the tibia nearer to the ilium r 
this band relaxes, and permits one to push more deeply inward on the 
injured side, between the great trochanter and the iliac crest, than 
on the sound side. 

The ascent of the great trochanter above Nelaton's line is another 
test. This line is taken from the anterior superior iliac spine to the 
most prominent part of the ischial tuberosity (Fig. 34). In health 

the great trochanter is below, and in intra- 
capsular fracture it is above this line. 

To test the ascent of the trochanter into Bry- 
ant triangle (Fig. 34), place the patient in a 
recumbent position ; carry a line around the 
body on a level with the anterior superior 
spines; lay down ISTelaton's line, and measure 
the base of the triangle from the great tro- 
chanter to the perpendicular line from the 
spine to determine the amount' of ascent. 

Morris' measurement shows the extent of 
inward displacement. Measure from the 
median line of the body to a perpendicular line drawn through the 
trochanter on each side of the body. 

Diagnosis of Intracapsular Fracture. — When, from the direc- 
tion of the force applied to the trochanter, the posterior wall of the 
neck is driven into the intertrochanteric line, the limb will be rotated 
outward, and the foot inverted; and when the anterior wall is driven 
into the bone, there will be inversion of the limb. The former form 
of accident is far more common than the latter, on account of the 
greater thinness of the posterior wall. Intracapsular fracture may 
be confused with extracapsular fracture or with a dislocation of the 
hip- joint. Extracapsular fracture, which is commonest in young 
adults, results from direct violence over the great trochanter. If non- 
impacted, there are noted shortening of from one and a half to over 
three inches, crepitus over the great trochanter, and usually, but not 
invariably, eversion; if impacted, there is less eversion; crepitus is 
almost or entirely absent, and the shortening is limited to about an 




Fig. 34— A CD Bryants 

Ilio-femoral Triangle. 

AB, Nealton's Line. 

(Owen.) 



Fractures. 



783 



inch. Great tenderness exists over the great trochanter, in both im- 
pacted and non-impacted fractures. In dislocation on the dorsum of 
the ilium, the patient is usually a strong young adult. There are 
inversion (the ball of the great toe resting on the instep of the sound 
foot), rigidity, ascent of the bone above Nealton's line, and shortening 
of from one to three inches. In dislocation into the thyroid notch, 
there is possible eversion, but it is linked with lengthening. 

Prognosis. — The prognosis is not very favorable. Old people 
not unusually die. In impacted fracture, bony union may occur; in 
non-impacted fracture fibrous union is the best that can be expected. 
]^on-union is not unusual. Permanent shortening to some degree is 
inevitable, and the function of the joint is sure to be more or less 
impaired. It will be found necessary in many cases for the patient 
always to employ support in walking. 

Treatment. — In treating a very old or feeble person for intra- 
capsular fracture, make no attempt to obtain union. Keep the patient 
in bed for two weeks ; give lateral support by sand-bags ; tie around the 
ankle a fillet, to which attach a weight of a few pounds, and hang the 




Fig. 35. — Adhesive Strips for Extension Apparatus. 



weight over the foot-board of the bed. When pain and tenderness 
abate, order the patient to get into a reclining chair, and permit him 
very soon to get about on crutches. If hypostatic congestion of the 
lungs sets in, if bed-sores appear, if the appetite and digestion utterly 
fail, or if diarrhea persists, abandon attempts at cure in any case, and 
secure for the sufferer sunshine and fresh air. Immobilize the frac- 
ture as thoroughly as possible by means of pasteboard splints. If it 
is determined to treat the case, combine extension with lateral support 
by means of sand-bags and the extension apparatus originally devised 
by Gurdon Buck. Place the subject on a firm mattress, and if the 
patient be a man, shave the leg. Cut a foot-piece out of a cigar-box; 
perforate it for a cord ; wrap it with adhesive plaster, run the weight- 
cord through the opening in the wood, and fasten a piece of plaster on 
each side of the leg, from just below the seat of fracture to above the 
malleolus. The plaster is guarded from sticking to the malleoli by 
having another piece stuck to it at each of these points. Apply an 
ascending spiral reverse bandage over the plaster to the groin (see 
Fig. 36), and finish the bandage by a spica of the groin. Slightly 
abduct the extremity. Put a brick under each leg of the bed at its 



784 Fractures. 

foot, thus obtaining counter-extension by the weight of the body. Run 
a cord over a pulley at the foot of the bed, and get extension by the 
use of weights, such as shot, fine rocks, or brick. From ten to fifteen 
pounds will probably be necessary at first, but after a day or two from 
six to eight pounds will be found sufficient (remember that a brick 
weighs about five pounds). Make a bird's-nest pad of oakum for the 
heel. Take two canvas bags, one long enough to reach from the crest 
of the toe to the malleolus, the other long enough to reach from the 
perineum to the malleolus. Fill the bags three-quarters full of dry 
sand, sew up their ends, cover the bags with slips, and put them in 
place in order to correct eversion. The slips may be changed every 
^ third or fourth day. The bowels are to be emptied, and the urine is 
to be voided into a bed-pan, unless using a fracture bed. Maintain 
extension for five or six weeks. Then mould pasteboard splints upon 
the part, and keep the patient in bed for three or four weeks more. 
In from eight to ten weeks after the accident, the patient may get 
about on crutches. Union, if it takes place, is cartilaginous, and not 




Fig 36. — Adhesive Plas/er Applied to Extension. 

bony, and there is bound to be some shortening and some stiffness of 
the joint. Passive motion is not made until after eight weeks have 
elapsed. Professor Senn claims that by his method of "immediate 
reduction and permanent fixation," bony union is obtained in fracture 
of the neck of the femur within the capsule. He "places the patient 
in the erect position, causing him to stand with his sound leg upon a 
stool or a box about two feet in height. In this position he is sup- 
ported by a person on each side until the dressing has been applied 
and the plaster has set." 

EXTRACAPSULAR FRACTURE. 

The line of extracapsular fracture is at the junction of the neck 
with the great trochanter, and is partly within and partly without 
the capsule, the fracture being generally comminuted and often im- 
pacted. The cause is violent force. This fracture is most usual 
in strong young adults. 

Symptoms. — When impaction is absent, there is marked crepitus, 
which is manifested most when the fingers are put over the great 
trochanter. There are great pain, swelling, and ecchymosis. There 
is absolute inability on the part of the patient to move the limb, and 



Fractures. 785 

passive movements cause great *pain. There is shortening to the extent 
of at least one and a half inches, and often three inches ; and there is 
absolute eversion with slight flexion of both the legs and the thigh. 
All these symptoms follow violent direct lateral force. In impacted 
forms of extracapsular fracture, in addition to the aid given the sur- 
geon by the history, there is severe pain, which is intensified by 
movement or pressure. Shortening exists to the extent of one inch 
at least, which is not corrected by extension. There is also great loss 
of function, and whereas the limb may be straight or even inverted, 
it is usually everted. Crepitus can not be obtained without improper 
violence, and the trochanter moves in a large arc of rotation, although 
it is in Bryant's triangle and above Nelaton's line. 

Treatment. — In treating extracapsular fracture, make extension, 
raise the foot of the bed, apply the extension apparatus with sand- 
bags for four weeks ; then apply a plaster dressing, and get the patient 
up on crutches. Remove the plaster at the end of four weeks. In 
impacted fracture, use a moderate force in extending, but never vio- 
lently pull the bones apart. (Da Costa.) 

FRACTURE OF THE SHAFT OF THE FEMUR. 

This may take place in any part, but is more common in the cen- 
ter than elsewhere, and as a consequence of indirect violence. It may 
occur, however, as a result of direct force, and more rarely of muscular 
action. The fracture may be transverse, oblique in any direction, 
vertical, dentated, comminuted, or impacted, the nature of the force 
and its direction determining these points. A sharp blow is likely to 
be followed by a transverse fracture ; a crushing force by a comminuted 
one; an indirect fracture probably will be oblique, according to the 
natural bend in the lower part of the limb. In the upper third the 
bone may be broken obliquely from above, and in front downward 
and outward, and from impaction of the lower extremity into the 
upper the latter fragment may be comminuted, the bone splitting sec- 
ondarily upward into the neck. 

Diagnosis. — There is usually no difficulty in diagnosing a frac- 
ture of the shaft, the following symptoms being usually present: A 
fall or injury, followed by loss of power in the limb ; shortening, 
which extension can rectify; deformity, probably angular; extra 
mobility of the lower part of the injured limb ; crepitus ; and probably 
the projection of one end of a fragment, with eversion of the foot. 
When the fracture is transverse, the shortening will rarely be marked. 
When it is oblique, the direction of the angular deformity often indi- 
cates the line of the obliquity. In young children, where the fracture 
is incomplete, shortening with boning of the limb after an accident, 
and an indistinct sensation of yielding on manipulation, with or 
without a peculiar crackling sensation, indicate the nature of the 
accident. 

50 



786 Fractures. , 

Treatment. — The fragments having been carefully adjusted by 
means of extension and gentle manipulation, the mechanical treat- 
ment of these fractures consists in the maintenance of extension by 
means of some applied force, and the complete rest of the coaptated 
bones, gentle compression of the affected part sometimes being bene- 
ficial. To assist the surgeon toward these ends, some anaesthetic may 
be used, if the pain is severe, and it is impossible by other means to 
keep the patient at rest, and any spasmodic action of the muscles 
interferes with the surgeon's aim. (Bryant.) 

Every surgeon is expected to use some one of the various splints, 
according to his fancy. We have the example of Paget and Callen- 
cjer 1 as a warrant for dispensing with all apparatus, "the child being 
laid on a firm bed, with the broken limb, after setting it, bent at the 
hip and knee, and laid on its outer side." 

Dr. Sans, 2 of New York, warmly advocates the plaster-of-Paris 
bandages. Bell 8 has spoken in strong terms of the advantages of this 
method. J. H. Packard, M. D., states that his own experience with 
it has been very favorable, but it needs to be carefully watched, lest,, 
on the one hand, the compression exerted should be too severe, or, on 
the other, with the subsidence of swelling, there should be too little 
control of the fragments. 

Hamilton recommends a sort of box, consisting of two long splints, 
one on each side, extending from the axillae to beyond the soles, where 
they are connected with a foot-piece. This latter is so long as to 
keep the feet widely separated. Coaptation splints of binder's board 
are applied to the injured thigh, and the leg is bound to the corre- 
sponding long splint with a roller. The remainder of the limb, the 
opposite limb, and the body are made fast with broad, separate strips. 

Vertical extension is advocated by Kummel. 4 Smith's well- 
known anterior wire frame is reported by Wright 5 to have been used 
with good result in a case of fracture somewhat above the middle of 
the bone, in a child five years old. 

Whatever plan of treatment may be adopted, children with frac- 
ture of the femur can not be prevented from wetting the bed, unless 
care is taken to protect it. Perhaps the best way to do this is to have 
a thin square pad of absorbent material, with oil silk or rubber cloth 
beneath it, properly placed to receive the urine, and changed as often 
as it becomes soiled. 

As to the fecal discharges, they should be received in a bed-pan, 
which should be warmed and very carefully placed under the child., 
the sound limb being raised for the purpose. 



lu Clinical and Pathological Observations in India," p. 237. 

2 New York Journal of Medicine, June, 1871. 

z Archives of Pediatrics, May, 1884. 

4 American Journal of the Medical Sciences, July, 1882. 

5 " Transactions of the Medical Association of Georgia," 1879. 



Fractures. 787 

Union is sometimes very slow in occurring. 

Poinsot 1 reported a case where a boy aged ten years had a frac- 
ture just below the trochanters, which did not consolidate for six 
months. The delay was ascribed to "local scurvy." Marks has re- 
corded the case of a girl aged fourteen who at the age of two and 
a half years had a fracture of the femur at two points ; it did not 
unite for six months, when a fragment was removed from the lower 
portion; the muscle shrank, and the knee became stiff. At thirteen 
years and seven months, the bone was again broken at the junction of 
the middle and lower thirds. Plaster of Paris was applied for three 
months, and then the fractured ends were rubbed upon one another. 
The plaster was reapplied, and she got up upon crutches. Union was 
finally obtained with one and one-fourth inches shortening. 

Compound fractures of the femur are very rare in children. 
They are to be treated on the same principles as in adults, but, as in 
other parts of the body, the youth of the patient affords more chance 
for successful conservative surgery. 

Sir A. Cooper relates the case of a boy who had his leg entangled 
in a wheel and sustained a transverse fracture, with separation of 
the external condyle, which exfoliated. Ankylosis was expected, and 
the limb was dressed in the straight posture, but five months after 
the accident the boy walked well, with free use of the joint. 

Langenbeck treated a boy aged six who by a fall had a T- 
fracture of the condyles, the knee-joint being full of blood; yet 
recovery took place with almost normal movements, and no shortening. 
A case of separation of the inner condyle of a boy aged fifteen, by 
the kick of a horse, was reported to Hamilton by Riggs. The whole 
leg. with the fragment, was displaced upward and inward, reduction 
being accomplished with much difficulty ; but a good recovery ensued. 

Fracture of the Bones of the Leg. — These are comparatively 
infrequent in early life, although in a number of instances reported 
they have occurred to children within the womb. Malgaigne, among 
^Ye hundred and fifteen cases of fracture, found but one as young 
as four years, and but twelve between five and fifteen years. Frac- 
ture of the fibula is more common than that of the tibia, particularly 
in its lower third (in adults) ; and it is believed that in many 
examples of what are called bad sprains, a fracture exists. Fracture 
in the upper two-thirds is usually caused by direct violence, but 
it may be by indirect violence, such as a wrench or twist of the 
ankle-joint. Under such conditions the fracture will be oblique. 
In the lower third the violence is commonly indirect, such as a lateral 
twist or a forcible eversion of the foot. 

Diagnosis. — The diagnosis may be somewhat difficult, and more 
particularly when no displacement is present. Crepitus may at times 
be made out by a forcible attempt to move or bend the lower fragments 



1 Bull. et Mem. de la Sociate de Chirurgie, October, 1878. 



788 Fractures. ■ 

or by some sudden inversion or eversion of the foot; but in trying 
for this, there is danger of harm being done. Local pain, caused by 
pressure with the thumb over the seat of fracture, and linear ecchy- 
mosis a few days after the accident, are valuable helps to diagnosis 
in these as in all other kinds of fracture. 

Treatment. — In fracture of either of these bones, a natural splint 
is always found in the same bone ; consequently, shortening or deform- 
ity rarely follows the accident. The surgeon has simply to apply 
some splint to insure rest to the broken bone and to the muscles that 
move the foot — to the inside of the leg when the fibula is broken, 
and to the outside when the tibia is fractured. The splints should 
have a foot-piece. In fracture of the lower third of the fibula the 
foot may be drawn inward, the bandage being applied from without 
inward; but in many instances nothing more is called for than abso- 
lute rest. In other cases a thick pad is often of use opposite the 
seat of fracture. In no case should the bandage cover the fracture. 
After the lapse of a few days, or at most a week, when all swelling, 
with other evidence of local injury, has subsided, the limb may with 
advantage be put up in some immovable apparatus. 

Fractures of Both Bones. — These occur in every variety. The 
most common is the transverse, about three inches above the ankle; 
but every form of oblique, dentated, comminuted, and vertical fracture 
is met with. When near the joint, the vertical into the joint is by 
no means rare. 

Symptoms. — The symptoms of fracture of the leg are too plain 
to be overlooked. The tibia being a superficial bone, any solution 
of continuity or deviation of the line of its spine is readily made 
out, the nature of the accident, loss of power, deformity, and crepi- 
tus helping the diagnosis. In fractures close to the ankle, accom- 
panied with displacement, dislocation may be roughly simulated; 
but the slightest care ought to detect the true nature of the case. The 
facility with which the displacement of the parts is rectified, the 
fact that the malleoli retain their normal relative position with the 
foot, and the ankle-joint moves with facility, proves that the dis- 
placement is due to the broken bones, and not to dislocation of the 
joint. When the lower epiphysis of the tibia is displaced with the 
foot, there may be some difficulty in making out the true state of the 
case, but such an accident can occur only in children. It will appear 
as a transverse fracture, but with no sharp edge of bone, as is usual 
in fracture, while replacement of the displaced fragments will not 
give rise to the ordinary crepitus of broken bone, but to a more sub- 
dued sensation. (Bryant.) 

When a wound complicates the case, the diagnosis is readily made. 

Treatment. — In treating a simple fracture, reduce by extension 
and counter-extension, and use a fracture box. If the soft parts 
are bruised, use lead-water and laudanum; if they are lacerated, apply 
antiseptic dressings. The fracture box may be hung upon a gallows. 




pi air c/.—l, Demi-gauntlet Bandage; 2, Gauntlet Bandage; 3, Spica of the Thumb; 
Spiral Reverse Bandage of the Upper Extremity; 5, Recurrent Bandage of Stumps; 
Spiral Reverse Bandage of the Lower Extremity. 



J 



Fractures. 789 

After three weeks apply plaster of Paris bandage or silicate of soda 
dressing, and let the patient sit up in a chair daily for one week; 
at the end of this time the patient may get about with crutches. 
At the end of six weeks after the accident, remove the plaster, and 
let the patient move about on crutches for two weeks, and with a 
cane for two weeks more. If the fracture is compound, asepticize 
thoroughly, make a counter-opening, insert a drainage tube, dress 
with bichloride gauze, apply a plaster bandage, and cut trap-doors 
over the opening of the drainage tube. Remove the tube, as a rule, 
in about forty-eight hours; but the patient's temperature is a better 
guide than time. 

Fractures of the Bones of the Foot. — These are somewhat rare 
accidents. The cause of fracture of either the scaphoid, the cuboid, 
or any of the cuneiform bones is direct force. Fractures of the 
os calcis and astragalus arise, as a rule, from indirect force, such 
as falls, but the calcaneum may be broken by indirect violence. In 
rare instances the os calcis has been broken by contraction of the great 
calf muscles. 





Fig. 37. — Fracture Box. Fig. 38. — Double Inclined Plane 

Fracture Box. 

Symptoms. — In fracture of os calcis there are severe pain, swell- 
ing, crepitus, mobility, often an apparent widening of the bone, 
not unusually a loss of the arch of the foot. (Pick.) In some cases 
the posterior fragments are drawn up by the calf muscles, and in 
other cases there is deformity. In fracture of the astragalus, dis- 
placement may occur which resembles that of a dislocation. Crepi- 
tus may or may not be detected. If crepitus can not be found, it 
is not certain that a fracture is present, though the patient may be 
unable to stand and there may be swelling and pain on pressure. 
Fractures of the other bones may be hard to detect. 

Treatment. — To treat a fracture of the os calcis when no deform- 
ity exists, the fracture box (Fig. 37) is used for two weeks; main- 
tain the foot at a right angle to the leg; apply lead-water and lauda- 
num; then put on an immovable dressing, and let it be worn for 
four weeks. In fracture of the os calcis, with drawing up of the 
posterior fragment, flex the leg upon the thigh, extend the foot, and 
maintain this position by means of a band around the thigh, the 
band being fastened by means of a cord to a slipper, the leg restr 
ing upon its outer side. At the end of two weeks apply plaster, 
and let it be worn for four weeks. If the projecting fragment of 



790 Fractures. 

the os calcis can not be forced into place, and if it makes dangerous 
pressure upon the skin, excise it; if it does not make pressure which 
threatens sloughing, place the joint in a favorable position for anky- 
losis, and immobilize. In fracture of the astragalus, use a frac- 
ture-box, and then an immovable dressing, as in fracture of the os 
calcis without deformity. Fractures of the other bones of the tar- 
sus may require drainage and immovable dressing, excision, or even 
amputation. 

Fractures of the metatarsal bones are due to direct force, and 
are almost always compound. Fractures from crushes usually demand 
excision or amputation. When only one bone is broken, displacement 
is < slight, there is severe pain on motion and pressure, and crepitus 
can generally be obtained. A simple fracture of a metatarsal bone 
is dressed in a fracture-box for one week, and in immovable dressing 
for three weeks. 

Fractures of the phalanges of the toes are due to direct force, 
and are often compound. They may require immediate amputation. 

To treat a compound fracture where amputation is unnecessary, 
drain with strands of catgut for forty-eight hours, and dress anti- 
septically. At the end of this time, apply over the bichlorate gauze 
a gutta percha or a pasteboard splint extending from beyond the end 
of the toe to well up upon the sole of the foot, and fix the splint in 
place with a spiral bandage of the toe and instep. The splint is 
to be worn for four weeks. In a simple fracture, use a splint of 
gutta percha, pasteboard, or binder's board, and let it be worn for 
three weeks. 




Plate h. — i, Oblique or Crossed Bandage of the Angle of the Jaw, 2, Gibson's Bandage; 
3, Recurrent Bandage of the Head; 4, Crossed Figure-of-8 Bandage of Both Eyes; 5, 
Barton's Bandage or Figure-of-8 of the Jaw; £, Figure-of-8 Bandage of the Elbow. 



CHAPTER LXIII. 

SPRAINS, CONTUSIONS, WOUNDS, INJURIES OE JOINTS, 
AND DISLOCATIONS. 

SPRAINS AND CONTUSIONS. 

Sprains may be very slight or very serious indirect injuries. 
They include more or less severe overstretching, if not lacerations, of 
the ligaments that bind the bones of an articulation together, some 
fracture or tearing away of the bone at the attachment of the liga- 
ments. In children under ten, sprains of joints are liable to be com- 
plicated with some epiphysial separation or incomplete fracture near 
the epiphysial line, or some crushing or compression of the spongy 
bone tissue. In the more severe instances are included lacerations 
of the muscles, tendons, and soft parts that surround the joint. All 
such accidents require rest and time in their treatment in order that 
repair may be complete, since neglected sprains are often the cause of 
joint or bone disease. 

Contusions of joints, as direct injuries, always ought to be 
regarded in a serious aspect ; for a large amount of internal mis- 
chief may often be sustained with very slight external evidence of 
injury, and under certain conditions of health, a slight blow upon 
a bone is often enough to set up severe local action, or to excite 
chronic changes which may involve the integrity of the joint. During 
the period of the growth of bone in children, these observations have 
great force. The nature of the accident and the amount of force 
concentrated on the joint form the best index to the case, and under 
all circumstances the prognosis should be guarded and the treatment 
cautious. 

Treatment. — "In sprains of joints, rest is the first principle," 
said John Hunter, in 1787 (MS. lectures), and at the present day 
the same words are as pregnant with truth as when then spoken. 
Indeed, in simple cases of sprain by such treatment alone will con- 
valescence be established. When swelling and effusion into the 
joint ensue in the course of the second or third day after the acci- 
dent, the evidence of internal injury is more marked ; for such effu- 
sion means inflammation, or synovitis, which is to be treated by abso- 
lute rest, insured by the application of a splint, the local use of cold 
or warmth, according to the comfort afforded by either, and occa- 
sionally by leeches. 

(791) 



792 Sprains, Contusions, Wounds, Etc. 

If swelling of the articulation follows immediately upon the 
injury, effusion of blood into the joint is indicated, with or without 
fracture, but always with severe local mischief. Such cases should 
be treated by the employment of a splint, to insure immobility of 
the articulation, elevation of the injured joint with the patient reclin- 
ing, and the local application of a bag of pounded ice. If ice can 
not be obtained, a stream of cold water may be allowed to flow over 
the joint until the hemorrhage has ceased, all risks of inflammation 
in it are gone, and repair appears to be going on satisfactorily. As 
soon as the primary effects of the sprain and all signs of inflamma- 
tion have passed, the application of pressure to the joint by means 
of a bandage, or strapping with passive movement, is very efficient. 
When the joint is rendered very tense from effused blood, it may 
be aspirated. 

When the muscles over the shoulder-joint are severely bruised 
by a fall, much local pain may be produced, as well as want of power 
in the arm, exciting a fear of either bone or joint mischief; but a 
careful examination will show, if no roughness in the examination be 
used, that the joint can be passively moved without exciting pain, 
although if the patient attempts to set the muscles in action, pain 
is produced. The point is one of clinical importance, indicating that 
the mischief is in the muscle, and not in the articulation, the pain 
being excited by muscular action, and not by joint movement. (Bry- 
ant.) 

In delicate children all falls upon the hip, followed by pain, 
should be treated with rest and extreme care ; for a large number of 
cases of hip disease originate from some such trifling cause; and 
there is good reason to believe that the majority of hip-joint affec- 
tions might be prevented by proper attention (by rest) after slight 
injury. 

After-treatment. — When the immediate effects of the sprain have 
passed away, the local use of a stimulating liniment and moderate 
friction applied to the part expedites the cure and at the same time 
gives comfort to the patient. A local warm bath at intervals likewise 
relieves the stiffness of the joint. Whenever movement excites more 
than a momentary pain, rest should be observed; and if the pain con- 
tinues, some chronic inflammatory change ought to be suspected and 
treated. When weakness of the joint alone remains, a good bandage 
or strapping around the part, to give support, is of great benefit. 

Where much laceration of ligament has taken place, it is at 
times necessary for the joint to have some permanent artificial sup- 
port, in the form of either a splint, felt, leather casing, or bandage ; 
for no parts are repaired with less permanent power than ligaments. 
In the wrist, when much swelling exists, a sprain may be mistaken 
for a fracture or a fracture for a sprain, as fractures about the end 
of the radius are generally impacted, and not, consequently, attended 
by crepitus. Much care is necessary in the diagnosis of such cases. 
Many sprains of the ankle are also really cases of fracture of the 



Sprains j, Contusions, Wounds, Etc. 793 

fibula above the malleolus. The popular notion that a severe sprain 
is worse than a fracture is in the main true; and where the sprain 
is neglected, the case is always more tedious than that of a broken 
bone. In a severe sprain, place the extremity upon a splint, and 
to the joint apply flannel kept wet with lead-water and laudanum, 
iced-water, tincture of arnica, alcohol and water, or a solution of 
chloride of ammonium. The ice-bag should from time to time be 
laid upon the leg with a flannel between for a period of twenty or 
thirty minutes. Leeches around the joint do good. Constitutionally, 
employ the remedies for inflammation. These remedies are "general 
bleeding, arterial sedatives, cathartics, diaphoretics, diuretics, ano- 
dynes, antipyretics, emetics, mercury and iodides, stimulants, and 
tonics. 

"General Blood-letting. — When a patient is strong, young, and 
robust, venesection is suited to the early stages of an acute inflamma- 
tion. General blood-letting diminishes blood-pressure and increases 
the speed of the blood-current, thus amending stasis, absorbing exudate, 
and washing adherent corpuscles from the vessel-wall; furthermore, 
it reduces the whole amount of body-blood, thus forcing a greater 
rapidity of circulation, decreases the amount of fibrin and albumin, 
lowers the temperature, arrests cell proliferation, and stops the effu- 
sion of lymph." (Da Costa.) 

Arterial sedatives are of use before stasis is pronounced ; if used 
after it exists, they will increase it. If stasis exists, relieve it by 
bleeding before using the sedatives. Venesection abolishes stasis and 
lowers tension, and arterial sedatives maintain the effect and the 
ground which is gained. The arterial sedatives employed are aconite, 
veratrum viride, gelsemium, and tartar emetic. These sedatives 
lessen the force and frequency of the heart-beats, and thus slow and 
soften the pulse, and are suited to a robust person with an acute 
inflammation, but are not suited to a weak man in an adynamic state. 

Aconite is given in small doses, never in large amounts. One 
drop of the tincture in a little water is given every half hour until 
its effect is manifest on the pulse, when it may be given every two 
or three hours. 

Veratrum viride is a powerful agent to slow the pulse and to lower 
blood-pressure; it produces moisture of the skin and often nausea. 
It is given in one-drop doses by the physician only, until its physio- 
logical effects are manifested, when the period between doses is 
extended to two or three hours. Ten drops of laudanum given a 
quarter of an hour before each dose of aconite or of Veratrum viride 
will correct nausea. 

Gelsemium is an arterial sedative highly approved by Bartho- 
low. It is given in doses of ten drops of the tincture every three or 
four hours. 

Cathartics. — The tongue affords the chief indication for the use 
of cathartics. Treatment in an inflammation can be begun, if con- 



r 



794 Sprains, Contusions, Wounds, Etc. 

stipation exists, by giving a cathartic. Castor-oil can be given in 
capsules, or the juice of half a lemon can be squeezed into a tumbler, 
four ounces of oil poured in, and the rest of the lemon squeezed on 
top, thus making a not unpalatable mixture. Aloin, podophyllum, 
the salines, as salts and magnesia, and calomel, in from three to five- 
grain doses, followed by a saline, have their advocates. 

Diaphoretics are very useful. Dover's powder is commonly used, 
but pilocarpine is preferred by some. Camphor in doses of from 
five to ten grains is a diaphoretic, and so are antimony and ipecac. 
Acetate and citrate of ammonium, opium, alcohol, hot drinks, heat 
to the surface (baths, hot drinks, and hot-water bags), serpentaria, 
and guaiac are diaphoretic agents. 

Diuretics are useful in fevers when the urine is scanty and high- 
colored, and are valuable aids in removing serous effusions and other 
exudates. Among the diuretics may be mentioned calomel in repeated 
(small) doses, cocaine, caffeine, alcohol, digitalis, the nitrates, squill, 
turpentine, copaiba, and cantharides. The liquor potassa and the 
acetate of potassium are the best agents to increase the solids in the 
urine. Large draughts of water wash out the kidneys. The liquor 
potassse citratis in doses of gr. xxx is efficient. In weak heart, the 
citrate of caffeine is a good stimulant diuretic. 

Anodynes and hypnotics may be required in inflammation. 
Dover's powder, besides being diaphoretic, is anodyne. Opium acts 
well after bleeding or purgation. If it causes nausea, it should be 
preceded one hour by gr. xx or xxx of bromide of potassium. Opium 
is used by the mouth, by the rectum, or hypodermically. It is used 
when there is pain, but its use is not to be long persisted in if it 
can be avoided. It should be given in doses measured purely by 
the necessities of the case. 

Antipyretics are those remedies which lessen heat-production and 
those which increase heat-elimination; Quinine, salicylic acid, and 
the salicylates, kairine, alcohol, antimony, aconite, digitalis, cupping, 
bleeding, nitrous ether, antipyrine, antifebrine, phenacetine, opium, 
ipecac, cold to the surface, and cold drinks. "In surgical inflamma- 
tions it is rarely necessary to employ heroic means to lower tempera- 
ture." 

ANKYLOSIS. 

Definition.- — When a joint-inflammation eventuates in the forma- 
tion of new tissue in and about the joint, contraction of this tissue 
limits or destroys joint-mobility, producing the condition known as 
"ankylosis." Ankylosis may be complete (bony), or incomplete 
(fibrous) ; it may arise from contractures in the joint, or from con- 
tractures in the structures external to the joint. 

Treatment. — An effort should always be made to prevent an 
ankylosis by treating carefully any joint-inflammation, and by begin- 
ning passive motion at the earliest safe period. To limit inflamma- 



Sprains, Contusions, Wounds, Etc. 795 

tion is to prevent ankylosis. Many cases of fibrous ankylosis are 
improved by passive movement, massage, friction, stimulating lini- 
ments, galvanic current of electricity, inunctions of ichtliyol or mer- 
curial ointment, or hot and cold douches. Some cases may be straight- 
ened out slowly by screw-splints or by weights and pulleys. Fibrous 
ankylosis of the elbow is best treated by using the joint. Fibrous 
ankylosis is often corrected by forcible straightening. If the 
tendons are much contracted, tenatomy should be performed two or 
three days before forcible straightening is attempted. In order to 
straighten, always give ether. Suppose a case of ankylosis of the 
knee, put the patient upon his back, bring the leg over the end of the 
operating-table, grasp the ankle with one hand and the lower portion 
of the leg with the other hand, and make strong, steady movement of 
flexion and extension until the limb can be straightened. The adhe- 
sions will be felt to break, the snapping often being audible. At once 
apply a plaster-of-Paris dressing, and keep the limb immobile for 
two weeks. This procedure is not free from danger. Vessels may be 
ruptured, nerves ma}' be torn, skin and fascia may be lacerated, sup- 
puration may ensue from the admission into the joint of encapsuled 
cocci, and organisms in the blood may find this area a point of least 
resistance. Because of the danger in a tubercular or a septic arthritis, 
do not forcibly break up an ankylosis, but use gradual extension by 
weights or by screw-splints. (Da Costa.) 

WOUNDS OF THE JOINTS. 

These are always serious accidents, yet as a whole, if treated with 
discretion and at an early period of their existence, they are fairly suc- 
cessful in their issue. 

A joint is known to be wounded when its contents escape, the 
oily, glutinous nature of synovia rendering its flow very manifest. 
Joints are sometimes wounded without any evident escape of their 
contents ; such doubtful cases are clinically to be treated as cases of 
wounds. In every case of wounded joint, however trivial, and in all 
doubtful cases of wounded joints, the prognosis must be very guarded 
and the treatment cautious. 

Treatment. — A clean incised wound should be well cleansed with 
carbolic or iodine water, and its edges accurately adapted with sutures. 
A contused or lacerated one should likewise be well washed and the 
joint syringed, and if the edges of the wound are brought partially 
together, sufficient opening should be left for drainage. The wound 
in both cases should be dressed with some absorbent antiseptic dressing, 
such as carbolic, iodoform, or salicylate gauze. Probing must be 
avoided, and the joint should be kept in absolute repose by the appli- 
cation of a padded splint. Cold should then be applied, nothing check- 
ing pain or subduing inflammation and effusion better. The cold, 
however, to be of value, must be persistently maintained, as any inter- 
mission of its use is almost sure to be followed by increase of pain 



796 Sprains, Contusions, Wounds, Etc. 

and effusion. If ice can not be obtained, frequent applications of cold 
cloths may be allowed to lay over the wound. To seal hermetically a 
small wound with a piece of lint soaked in the compound tincture of 
benzoin, and at the same time apply cold, is excellent practise. Should 
an interval have passed between the accident and the application of 
the cold, and much joint inflammation exist with constitutional symp- 
toms, the application of leeches to the joint, and subsequently of cold, 
is beneficial. In exceptional examples, where cold is not tolerated, 
warm fomentations must be substituted. Opium is always of use, the 
patient being kept fairly under its influence by one grain two or three 
times a day. Mercury is useless. Give colchicum where gout is sus- 
pected. In feeble patients tonics are required. When all acute 
symptoms have subsided, and chronic effusion remains, the application 
of a fly-blister or of blisters, expedites the absorption of the effused 
fluid, and the benefit of pressure by the adjustment of well-applied 
strapping is very great. In feeble patients tonics are required. 
Should suppuration appear, active treatment is called for, such as a 
free incision into the joint (in case of abscess) as soon as any pus 
can be detected. The limb should be raised, the joint preserved at 
rest by splints, and warm-water dressing or a flaxseed poultice applied ; 
and the joint should be kept absolutely quiet till repair has been com- 
pleted. (Bryant.) 

The best treatment for knee-ankylosis is the use of the joint. 



CHAPTER LXIV. 

« 

DISLOCATIONS. 

Definition. — Dislocation is the persistent separation from each 
other, partially or completely, of two articular surfaces. 

PREDISPOSING CAUSES. 

Age. — Dislocations are commonest in middle life, the usual lesion 
of the young heing green-stick fracture, and that of the old being 
fracture. Dislocations of the radius are not uncommon in youth. 

Muscular Development. — Dislocations are most common in those 
with powerful muscles. 

Sex. — Males are more predisposed than females, because of their 
occupations and muscular strength. 

Occupation is a predisposing cause, according as it demands the 
employment of muscular force, as in the carrying of burdens. 

Nature of the Joint. — Ball-and-socket joints are more liable to 
dislocation than are ginglymus joints, because of their wide range of 
motion. Joint disease predisposes by relaxing the ligaments. 

Exciting Causes. — These are external violence and muscular 
action. External violence may be direct, as when a blow upon one 
of the bones forces it directly away from the other ; or it may be indi- 
rect, as when a blow at a distant part of a bone transmits force to its 
end, and drives the bone out of its socket. Muscular action is a cause 
when sudden and violent muscular contraction occurs, when the joint 
is in a position which gives the muscles full sway, and throws the head 
of the bone against the weakest part of its retained ligaments. 

Pathological Conditions. — In a recent complete traumatic dis- 
location the ligaments are damaged, and may perhaps show extensive 
laceration, or may show only a button-hole laceration, through which 
a bone projects. External force produces much laceration and little 
stretching of the ligaments ; muscular action produces little laceration 
and much stretching of the ligaments. (Mears.) In some cases of 
dislocation due to external violence, the structures about the joints are 
bruised or otherwise damaged, the old socket is filled with blood, and 
the bone in its new situation lies in a bloody area. Large vessels and 
nerves are rarely torn, though they may be much compressed. 

If a dislocation is not soon reduced, inflammation arises in the 
old joint and about the displaced bone, and the whole area is glued 
together, first by coagulated exudate, and next by embryonic tissue. 
After a time, in ball-and-socket joints, the old socket fills with fibrous 

(797) 



798 Dislocations. 

tissue, contracts, becomes irregular, and may even be obliterated. The 
bead of the dislocated bone alters its shape, its cartilage is destroyed or 
converted into fibrous tissue, and the pressure of the head of the 
bone forms a hollow in its new situation, which hollow becomes sur- 
rounded by fibrous tissue or even by bone. A new joint may form, 
the surrounding tissue becoming a compact capsule, and a bursa form- 
ing between the head of the bone and its new socket. In a dislocated 
hinge- joint the ends of the bone alter greatly in shape, and their car- 
tilage is converted into' fibrous tissue. In an unreduced dislocation 
the muscles shorten, or lengthen, or undergo atrophy or fatty degen- 
eration, as the case may be. An unreduced dislocation of the ball-and- 
socket joint may give a fairly movable new joint, but an unreduced dis- 
location of a hinge- joint rarely allows of much motion. 

General Symptoms of Traumatic Dislocations. — In general, trau- 
matic dislocations are indicated, first, by pain of a sickening, nau- 
seating character; second, by rigidity. Voluntary motion is impos- 
sible, except to a slight extent in the direction of the deformity. For 
instance, in a dislocation of the inferior maxillary, the jaw can be 
opened a little more, but it can not be closed. This rigidity brings 
about loss of function. When the surgeon attempts to move the joint, 
he finds it very rigid. Third, by change in the shape of the joint, as 
flattening of the shoulder after dislocation of the humerus. Fourth, 
by alteration in the mutual relations of bony prominences about a 
joint (alteration of the relation between the olecranon and humeral 
condyles in dislocation of the elbow backwards). Fifth, by feeling the 
displaced bone in its new situation. Sixth, by missing the head of 
the bone from its proper situation. Seventh, by alteration in the 
length of the limb (in dislocation of the femur into the thyroid fora- 
men the leg is lengthened, but in dislocation into the dorsum of the 
ilium it is shortened). Eighth, by alteration in the axis of the bone. 
In dislocation upon the dorsum of the ilium, the axis of the injured 
thigh would, if prolonged, pass through the lower third of the sound 
thigh. 

Diagnosis of Traumatic Dislocation. — A dislocation may be mis- 
taken for a fracture. In dislocation there is rigidity; in fracture there 
is preternatural mobility. In dislocation there is no true crepitus 
(may get tendon or joint crepitus) ; in fracture there usually is 
crepitus. In dislocation the deformity does not tend to recur after 
reduction; in fracture it does recur after extension is relaxed. In a 
sprain the movements of the joint are only limited, not abolished by 
an almost complete rigidity. The change which a sprain may cause 
in the shape of a joint is due to effusion or to bleeding. There is no 
alteration in the relation of the bony prominences to one another. 
There is no notable alteration in the length of the limb (a slight 
increase in length may arise from joint-effusion, or the head of the 
bone may subsequently be absorbed, and thus produce shortening after 
some weeks). There is no alteration in the axis of the bone. The 



K^^^^^te^ JEb^'^A 


Ira '' ''•^■■■i " ^ 




■■r <^* 1 


■I ^ 1 ■ 

SIX ^H HHEHk VBE 



Pfete i. — i ? Figure-of-8 Bandage of the Ankle; 2, Method, of Covering the Heel; 3, Spica 
of the Instep; 4, Spica of the Groin; 5, Posterior Figure-of-8 of Both Shoulders; 6', Figure- 
of-8 of Neck and Axilla. 



Dislocations. 799 

head is not felt in a new position, it being found in its normal place. 
Always remember that a fracture may exist with a dislocation. In 
any doubtful case, — in fact, in most cases, — give ether, for a disloca- 
tion should be reduced while the patient is anaesthetized, except in dis- 
location of the jaw, of the fingers,, of the carpus, etc. In some cases 
swelling renders the diagnosis difficult or impossible. Always com- 
pare the injured joint with the corresponding joint of the sound side. 
(Da Costa.) 

Treatment. — In all cases the reduction of the dislocation or dis- 
placement should be effected as soon as possible, delay being justifiable 
only when the appliances required for the purpose are not at hand, or 
the diagnosis is uncertain. Most dislocations, not excluding those of 
the hip, may be readily reduced directly after their occurrence by 
extension or manipulation without the aid of an anesthetic ; but when 
any time has been allowed to pass and the immediate constitutional 
effects of the accident have subsided, it is a fair question whether it is 
advisable to attempt reduction before anesthetizing the patient ; for 
under the most favorable circumstances, without this aid much force 
will to a certainty be called for, whilst with it the gentlest manipula- 
tion is often enough. In no department of surgery is the benefit of 
anesthetics better demonstrated than in this ; for where force was for- 
merly practised, gentleness now suffices, and where difficulty and pain 
were common accompaniments, facility of reduction and painlessness 
are now the rule. Under their influence all muscular spasm ceases to 
be a force which has to be overcome, and the surgeon has simply to 
replace the bone through the rent in its capsule by such gentle maniptv- 
lative acts as the special requirements of each case appear to indicate. 
The facility, however, with which a dislocation is reduced by manipu- 
lation turns much upon the surgeon's knowledge of the way the dislo- 
cation was produced ; for, in a general sense, the best way to reduce a 
dislocation is to make the head of the bone retrace the course it fol- 
lowed after it had first burst through its capsule, the untorn parts in 
the capsule being doubtless the main obstacle to reduction. Muscular 
spasms are eliminated by the use of an anesthetic. 

In neglected cases of dislocation, where false joints and adhesions 
exist, force is called for to break them down, and pulleys may be 
wanted; but they must always be employed with the greatest caution, 
for fear of injury to the axillary artery, and laceration of the ligaments, 
injuries which we see mentioned in reported cases. 

After-treatment. — After the reduction of a dislocation, the limb 
should be kept at rest and fixed by bandages on a splint. Sedillot's 
rule of simply placing the joint in a position the opposite of that in 
which it was when the dislocation occurred, is sound. When any signs 
of inflammation show themselves, cold, in the shape of ice in a bag, 
should be employed ; leeches are seldom called for. 

At least three or four weeks are required for repair to take place 
before any useful free movement of the joint can be allowed, although, 



800 Dislocations^ 

when no inflammatory symptoms appear, passive movement may be 
permitted at the end of two weeks. In dislocation of the hip, no walk- 
ing or standing should be permitted for a month. 

When reduction can not be accomplished after a reasonable 
attempt, a second one may be made at a subsequent period after the 
effects of the first have passed; that is, if any sound hope exists of 
success being secured, some modification of the means employed prob- 
ably suggesting itself to the surgeon upon reflecting as to the peculiarity 
of the case and the cause of his failure. 

When the patient is an adult, the difficulties and prospects of the 
case should be laid before him and his opinion taken, not, however, 
as to the desirability or the reverse of the attempt, for such an opinion 
belongs to the surgeon and his colleagues only, but as to the risks that 
must be run; for in many reported cases failure of reduction — more 
particularly of forcible reduction — is followed by some destruction of 
the new joint that nature has partially formed, by some inflammatory 
change that may end in the destruction of the joint or in rendering its 
usefulness still less promising. 

DISLOCATION OF THE CLAVICLE. 

The causes of forward dislocation of the clavicle are blows, falls, 
or pulls, which drive or draw the shoulder backward. 

Symptoms. — When the dislocation is partial, some usual prom- 
inence of the end of the bone, on comparing it with its fellow, will 
suggest its nature, the bone being only covered with skin and readily 
pressed back. When complete, the nature of the accident will be still 
better marked, and the end of the bone will be usually found pointing 
downward. Inflammatory thickening of the joint should not be mis- 
taken for partial displacement. 

Treatment. — There is usually little or no difficulty in reducing 
' this form of dislocation by forcibly drawing back the shoulder and 
applying pressure to the displaced bone, though there is great difficulty 
in keeping the boue in its normal position; indeed, as a rule, it is 
quite impossible to do this satisfactorily. Bryant states that he has 
succeeded by keeping the patient on his back in bed for three weeks, 
with his arm bound to his side. A pad in the axilla, with a figure-8 
bandage to keep the shoulder outward, the elbow being bound to the 
side, will do much towards the desired end, and a pad of lint applied 
outside the displaced end of the clavicle and firmly fixed in position 
by strapping carried over the shoulder and scapula, is very beneficial. 

DISLOCATION OF THE SCAPULA. 

The symptoms are well marked. The falling of the shoulder and 
projection upward of the acromial end of the clavicle in one, and the 
projection upward of the acromion process of the scapula in the other, 
prevents any mistake being made. 



Dislocations. 801 

In the more usual form of this accident the acromion process of 
the scapula is forced beneath the clavicle. In rare cases it may be 
received above it. Both are commonly caused by direct violence to 
the shoulder. 

Treatment. — In the dislocation of the scapula downward the aim 
of the surgeon is to raise the scapula with the arm and depress the 
clavicle, which is best done by drawing the elbow well backward and 
applying a pad over the clavicle, the pad and elbow being fixed in 
position by means of a belt or plaster-of-Paris bandage passed over the 
clavicle and round the elbow. The belt presses the clavicle downward, 
and raises the shoulder and arm upward. The surgeon, in all cases 
recognizing the special wants of the case, must adapt his monns to 
meet them in the best possible way. Good movements of the arm are, 
as a rule, acquired in time after either of these accidents. (Bryant.) 

The treatment of dislocation of the lower angle of the scapula 
comprises massage, electricity, passive motion, and deep injections of 
strychnse. 

DISLOCATIONS OF THE HUMERUS ( SHOULDER- JOINT ) . 

These injuries are most frequent because of the free mobility of 
the shoulder- joint, its anatomical insecurity, and its exposed situation. 
These dislocations are rare in the very young and in the aged, being 
oftenest encountered in muscular young adults. Four forms of 
shoulder- joint dislocations exist, namely: First, forward, inward, and 
downward, under the coracoid process — subcoracoid; second, down- 
ward, forward, and inward, beneath the glenoid cavity — subglenoid; 
third, backward, inward, and downward, under the spine of the scap- 
ula — subspinous ; and fourth, forward, inward, and upward, under the 
clavicle — subclavicular. 

SUBCORACOID DISLOCATION. 

This may be caused by direct force driving the head of the 
humerus forward and inward, or by indirect force, such as falls upon 
the hand or the elbow. 

SUBGLENOID OR AXILLARY DISLOCATION. 

This form of dislocation may be produced by contraction of the 
great pectoral and latarsimus-dorsi muscles when the arm is at a right 
angle to the body; but it is usually due to falls upon the hand or the 
elbow when the arm is raised, and the head of the bone is against the 
lower portion of the capsule. In this dislocation the head of the bone 
rests upon the border of the scapula, below the tendon of the sub- 
scapulars, in front of the long head of the triceps above the teres 
muscles. 

51 



802 



Dislocations. 



SUBSPINOUS AND SUBCLAVICULAR DISLOCATIONS. 

These are very rare injuries. They are caused by the same sort 
of violence which produces subcoracoid dislocations. In the very rare 
form known as the "supracoracoid," the head of the coracoid is always 
fractured. 

Symptoms of Dislocation of the Shoulder- joint. — Dislocation is 
diagnosticated by, first, pain of a sickening character; second, flatten- 
ing of the shoulder, the head of the bone having ceased to bulge out 
the deltoid muscle; third, apparent projection of the acromion through 
sinking in of the deltoid ; fourth, a hollow beneath the acromion, over 
the empty glenoid cavity, and the bone missed from its normal habitat ; 
fifth, rigidity (some movement is possible, in the direction especially 
of an existing deformity, but mobility is strictly limited, and attempts 
at motion produce great pain) ; sixth, the elbow does not touch the side 
when the hand is placed upon the sound shoulder (Dugas' sign. This 
is due to the rotundity of the chest. In a dislocation the head of the 
bone is already touching the chest, and the bone, being approximately 
straight, can not touch it in two places at the same time. If the elbow 
can be placed against the chest with the hand on the sound shoulder, 
there can be no dislocation; if it can not be so placed, there must be 
dislocation) ; and, seventh, finding the head of the bone in a new situa- 
tion. Most of these symptoms may be grouped as Erichson's list of 
signs. 

The following table, from T. P. Pick's work on fractures and 
dislocations, makes the above points clear : — 



Subcoracoid. 



Subglenoid 



Subspinous 



Subclavicular. 



Direction or the 

Axis or the 

Limb. 



The elbow is carried 
backward and slight- 
ly away from the 
side. 



Alteration in the 

Length of the 

Limb. 



Very slightly length- 
ened. 



The elbow is carriedJVery considerable 
away from the trunk! lengthening, 
and slightly back- 
ward. 

The elbow is raised Lengthening inter 
from the side and mediate in degree 
carried forward. between the subgle- 

noid and the subcor- 
acoid 

Shortening. 



The elbow is carried 
outward and back- 
ward. 



Presence or the Head of 
the Bone in New Sit- 
uation. 



The head of the bone can not 
easily be felt; if it can, it 
is found at the upper and 
inner part of the axilla. 

The head of the bone can 
easily be felt in the axilla. 



The head of the bone can be 
felt and grasped beneath 
the spine of the scapula. 






The head of the bone can 
readily be seen, and can be 
felt beneath the clavicle. 



In a shoulder- joint dislocation the head of the bone may press 
upon the brachial plexus and produce pain and numbness, and some- 



Dislocations. 803 

times a traumatic neuritis or paralysis ; sometimes pressure upon the 
axillary vein causes oedema, and pressure upon the axillary artery 
diminishes or obliterates the pulse. The axillary vessels may be 
torn and the muscles may be lacerated badly. The capsule is torn, and 
considerable blood is usually effused. Swelling is due, first, to hemor- 
rhage, and, secondly, to inflammation. 

Diagnosis of Shoulder- joint Dislocation. — In fracture of the neck 
of the scapula there is prominence of the acromion and a hollow below 
it, a hard body being felt in the axilla; but the coracoid process 
descends with the head of the bone, which it does not do in dislocation. 
Furthermore, in fracture there is rigidity; in dislocation, mobility. 
In fracture crepitus is present ; in dislocation it is absent. In fracture 
the deformity is easily reduced, but it at once recurs; in dislocation it 
can not be so manipulated. In fracture of the anatomical neck of the 
humerus, deformity is slight; the head of the humerus is found in 
place, and does not move when the shaft is rotated ; and the head is not 
in line with the axis of the bone. Crepitus exists in fracture if im- 
paction is absent. In paralysis of the deltoid there is distinct flatten- 
ing, but the bone is felt in place, and there is no rigidity. 

Treatment. — Reduction by manipulation is usually obtained in 
recent cases of shoulder- joint dislocation. Always give ether. For- 
ward dislocations (subcoracoid, subclavicular, and axillary) are reduced 
by Kocher's method. Put the arm against the side, flex the forearm 
to a right angle with the arm, perform external rotation of the arm 
until the forearm is at a right angle with the body, raise the elbow, 
make internal rotation, and place the hand on the opposite shoulder. 
The formula is, flexion of the forearm, external rotation, abduction, 
and internal circumduction of the arm. In reducing shoulder- joint 
dislocation, the surgeon uses his own judgment as to the various move- 
ments best suited to the case. Another method of manipulation is as 
follows: If the right shoulder is dislocated, the surgeon stands behind 
the patient (whose shoulders are raised) ; if the left shoulder is dis- 
located, he stands in front of the patient. The surgeon holds the arm 
flexed upon the forearm with his right hand, and makes external trac- 
tion and rotation, and with the fingers of his left hand he tries to force 
the bone into place. 

Reduction by Extension. — In reduction of shoulder- joint disloca- 
tion by extension the patient is anaesthetized and placed upon a low 
bed or upon the floor. The surgeon then places his foot, covered only 
by a stocking, in the axilla. Place the sole of the foot, not the heel, 
against the chest high up, the instep being made to touch the humerus 
and the heel the border of the shoulder-blade, a towel being first put 
into the axilla to rest the foot against. If the left arm is dislocated, 
use the left foot, or vice versa. Make steady extension, which will, in 
many cases, bring about the reduction. A good method, which is well 
thought of by some surgeons, is that in which the surgeon stands behind 
the patient, steadies the scapula with his foot or hand, and carries the 



804 



Dislocations: 



patient's arm above his head, making extension and external rotation. 
(Cooper.) Cock advises, when reduction fails, that an air-pad be 
placed in the axilla, and the arm be bound to the side, — a method by 
which reduction will often take place after two or three days. The 
pulleys are very rarely used, as they develop a dangerous force. 

After reducing a dislocation, apply a Velpean bandage, keep the 
shoulder immobile for one week ; then make passive motion daily. The 




Fig. 39. — Reduction of 
Shoulder-joint Dislocation 
by the Knee in the Axilla. 
(Cooper.) 




Fig. 40. — Reduction of Shoulder-joint 
Dislocation by the Foot in the Axilla. 
(Cooper.) 




Fig. 41- — Reduction of Shoulder- 
joint Dislocation by the Pulleys. 
(Cooper.) 




Fig. 42. — Reduction of Shoulder -joint 
Dislocation by Extension Upward. 
(Cooper.) 



patient may wear a sling alone during the third week, after which 
period he may use his arm. 

DISLOCATIONS OF THE ELBOW-JOINT. 

Injuries of the elbow-joint are not rare, and they are most com- 
mon in children. Both bones or only one bone may be dislocated, and 
the dislocation may be partial or be complete. The cause of backward 



Dislocations. 



805 



dislocations of both bones of the elbow- joint are falls upon the extended 
hand or twists inward of the ulna. The coronoid process lodges in the 
olecranon fossa. (Malgaigne.) 

Symptoms of Backward Dislocation. — In complete dislocations of 
both bones of the elbow- joint the olecranon is very prominent ; the dis- 
tance between the point of the olecranon and the apex of the inner 
condyle is notably greater than on the sound side ; the forearm is flexed, 
supinated, and shortened; the lower end of the humerus projects in 





Fig. 4$- — Kocher's Method of Reduction by Manipulation (Ceppi): 
a, first movement, outward rotation; b, second movement, elevation 
of elbow; c, third movement, inward rotation and, lowering of elbow. 

front of the joint, below the skin-crease; the head of the radius is found 
back of the outer condyle; there are the general symptoms of disloca- 
tion. Fracture of the coronoid rarely occurs with backward disloca- 
tion; but if it does occur, there will be crepitus and mobility. In 
fracture above the condyle there are found the ordinary symptoms of 
a fracture; measurement from condyles to styloid processes does not 
show shortening ; there is no alteration of normal relations between the 





Fig. 44- — Clove-hitch Knot Ap- 
plied above the Wrist. (After 
Erich sen.) 



Fig. 45- — Dislocation of Radius 
and Ulna Backward. (From Sir 
A. Cooper.) 



olecranon process and the condyles ; and the projection in front of the 
joint is above the crease of the bend of the elbow. 

Treatment of Backward Dislocation. — Reduction must be made 
early in dislocations of both bones of the elbow-joint, or it will be 
found impossible, and an unreduced dislocation means a limb without 
the powers of flexion, pronation, or supination. The surgeon places 
his knee in front of the elbow- joint, grasps the patient's wrist, pressed 
upon the radius and ulna with his knee, and bends the forearm with 



806 Dislocations; 

considerable force, the muscles pulling the bones into place. (Sir 
Ashley Cooper's plan.) Apply an anterior angular splint, and have 
it worn for two weeks. Make passive motion after a few days. 

DISLOCATION OF BOTH BONES FORWARD. 

The cause of forward dislocation of both bones of the elbow-joint 
is a blow on the olecranon when the arm is flexed. It is a rare acci- 
dent. 

Symptoms. — The symptoms of forward dislocation of both bones 
of the elbow- joint are : The forearm is flexed and lengthened ; some 
slight motion is possible ; the olecranon is on a level with the condyles, 
if unf ractured, hence its prominence is gone ; the humeral condyles are 
felt posteriorly, and the radius and ulna are felt anteriorly. 

Treatment. — The treatment of this injury is the same as that for 
dislocation backwards. Forced flexion and pressure may be employed 
for reduction. 

Symptoms and Treatment of Outward Dislocation. — The symp- 
toms of outward dislocation of both of the bones of the elbow-joint are: 
The forearm is flexed, fixed, and pronated; the joint is widened; the 
head of the radius projects externally, and has a depression above it; 
the inner condyle projects internally, and has a depression below it; 
the olecranon is nearer than normal to the external condyle, and 
further than normal from the internal condyle. Reduction is effected 
by extension of the forearm and pressure upon the head of the radius. 
Apply an ascending spiral reverse bandage to the forearm, a figure-8 
bandage to the elbow- joint, and a sling. Make passive motion after a 
few days. The bandage must be worn for two weeks. 

Symptoms and Treatment of Inward Dislocation. — In dislocation 
inward of both bones of the elbow- joint, the position of the forearm 
is the same as that in dislocation outward; the sigmoid cavity of the 
ulna projects internally, and the external condyle projects externally. 
The treatment of this form of elbow- joint dislocation is the same as 
that employed in the preceding form. 

Dislocation of the ulna alone is very rare, and can only take place 
backward. 

Symptoms and Treatment. — Dislocation of the ulna alone is indi- 
cated by the forearm being flexed and pronated. The head of the 
radius is found in place, and the olecranon projects posteriorly. The 
treatment of this injury is the same as that for the preceding disloca- 
tion. 

DISLOCATIONS OF THE RADIUS FORWARD. 

Dislocation of the radius forward is the most common form. 
This injury is caused by a fall upon the hand with the forearm in 
pronation and extension, or is produced by blows on the back of the 
joint ; forced pronation alone will cause it. 



Dislocations. 807 

Symptoms and Treatment. — The symptoms in dislocation of the 
radius forward are : The forearm is midway between pronation and 
supination, and semiflexed ; attempts to increase flexion cause the radius 
to strike against the humerus with a distinct blow; the head of the 
radius is felt in front of the outer condyle, and is missed from its 
proper abode. Reduction is effected by extension and manipulation. 
A padded splint is used as in dislocation of both bones. Deformity 
is apt to recur after reduction, because of rupture of the orbicular liga- 
ment. 

Treatment. — The treatment of dislocation of the radius backward 
is the same as that given in forward dislocation. 

Dislocation of the Head of the Radius. — This injury is very fre- 
quent in children between two and four years of age. It results from 
traction upon the hand or the forearm, and often arises when the nurse 
or mother pulls upon a child's arm to save it from a fall or to lift it 
over a gutter. Some writers hold that pronation is required, as well 
as extension, to produce the injury. Many surgeons claim that exten- 
sion and adduction are the causative forces. 

Symptoms.- — The history points to the injury. Pain, and often 
a click, may be felt in the wrist at the time of the accident. The arm 
hangs by the side, with the elbow- joint slightly flexed and the forearm 
midway between pronation and supination. Flexion and complete 
extension are resisted, and are very painful, but movements between 
60° and 130° are free and painless. 1 The movements of the wrist- 
joint are free and painless. The elbow presents no deformity. 
Pressure over the head of the radius causes pain. Strong pronation 
is painful. Strong supination is very painful. Forced supination 
develops a distinct click at the head of the radius, and causes pronation 
and supination to become natural and free from pain. The condition 
will be reproduced if a splint is not used. The nature of the lesion is 
said not to be understood, and various conditions have been thought to 
exist by different observers. Among them is mentioned the follow- 
ing : A slight anterior displacement ; 
locking of the tuberosity of the radius 
behind the inner edge of the ulna; dis- 
location of the triangular cartilage of 
the wrist ; intracapsular fracture of 
the radial head ; painful paralysis 
from nerve injury ; displacement by 
elongation, the return of the bone be- 
ing prevented by collapse of the cap- Fig. 46.— Anterior Angular Splint. 

sule, and slipping up of the margin of 

the orbicular ligament over the rim of the head of the radius. 

Treatment. — Place the forearm at a right angle to the arm, and 
make forcible supination; apply an anterior angular splint, and have 
it worn for four or five days. 

r W. W. Van Arsdale, in the "Annals of Surgery," vol. 9, 1889. 




808 Dislocations, 

DISLOCATIONS OY THE WRIST. 

These are very rare, and are caused by falls upon the hand. 

Symptoms of Backward Dislocation of the Wrist. — The deformi- 
ties in backward dislocation of the wrist are: The fingers are flexed; 
the wrist is bent backward; the radius projects on the front of the 
wrist; the carpus projects on the dorsal surface of the arm; the rela- 
tion of the styloid process of the radius to the styloid process of the 
ulna is unaltered; there is rigidity, and crepitus is absent. 

Treatment. — The treatment in both backward and forward dis- 
location of the wrist is extension and manipulation, a bond splint for 
ten days, and passive motion after five or six days. 

Dislocation at the inferior radio-ulnar articulation, which is also 
very rare, is caused by a twist. 

Symptoms. — In forward dislocation at the inferior radio-ulnar 
articulation, the forearm is pronated, the space between the styloid 
processes is diminished, and the ulna forms a projection posteriorly. 
In backward dislocation the forearm is supinated, the space between 
the styloid processes is diminished, and the ulna projects in front. 

Treatment. — This is by extension and manipulation. Two 
straight splints (as in fracture of both bones) are to be applied for 
four weeks, and passive motion is to be made in the third week. 

Pick says, in dislocation of individual carpal bones, that there is 
one weak spot, which is "between the head of the os magnum and the 
scaphoid and semilunar bones," and the os magnum may be forced up. 
The injury is caused by forced flexion of the wrist. 

Symptoms and Treatment. — The symptom of dislocation of the 
carpal bones is a firm projection, which becomes more prominent dur- 
ing flexion of the wrist. The treatment is extension and manipulation^ 
a bond splint being worn for three weeks. 

In all dislocations of the metacarpal bones, the treatment is exten- 
sion and manipulation, a straight splint well padded and a large pad 
for the palm, the splint to be worn for three weeks. 

Dislocations of the phalanges may be complete or may be partial. 

Treatment. — The treatment is extension and manipulation; wear 
a straight splint for one week. 

In dislocation of the ribs and costal cartilages, diagnosis is rarely 
made, and the injury is treated as a fracture. The ribs may be dis- 
located from their cartilages, one or more ribs being displaced. The 
treatment is the same as for fracture of the ribs. The dressings are 
the same as those used in fractured sternum. Pick states that reduc- 
tion is brought about by causing the patient to hold the chest full of 
air while efforts are made to push the cartilage into place. Dress the 
same as for fractured ribs. 

Pelvic dislocations are almost always complicated with a fracture. 
They are caused by falls from a height or applying violent force to 
the acetabula. The dislocation may be up or down, front or back, and 



Dislocations. 809 

may damage the urethra or the bladder. The patient can not stand. 
There are great pain and deformity. Treat by moulding the bones 
into place, by applying a pelvic belt, and by rest in bed for four weeks. 
Dislocations of the sacroiliac joint are produced by falls. Move- 
ment on the part of the patient is difficult or impossible. There is 
violent pain, and often paralysis (from pressure upon nerves). In 
dislocation backward there is an apparent shortening of the leg, ever- 
sion of the foot exists, and the ilium moves posteriorly and upward. In 
dislocation forward the anterior superior iliac spine projects, and the 
pelvis is broadened. Sacroiliac dislocations are reduced by holding the 
pelvis firm, and making extension with a pulley. The patient stays 
in bed for four weeks, and wears a pelvic belt, as in fracture. 

DISLOCATIONS OF THE FEMUR ( HIP- JOINT ). 

These injuries are rare, as the hip- joint is very strong. They 
occur in young adults. In forcible extension the head of the femur 
presses against the capsule, but the capsule here is very thick, and cer- 
tain muscles, the rectus, psoas, and iliacus, are pulled tight, and serve 
to strengthen the capsule. The head of the bone can not go directly 
upward, because of the acetabulum. (Edmund Owen.) The weak 
point of the acetabular rim is below. The weak part of the capsule is 
also below. Forced abduction is apt to take the head of the bone 
through the lower part of the capsule, a dislocation occurring primarily 
into the thyroid foramen. Four forms of hip- joint dislocation exist: 
First, upward and backward on the dorsum of the ilium ; second, back- 
ward into the sciatic notch; third, downward into the obturator fora- 
men; and, fourth, inward on the pubes. 

DISLOCATIONS ON THE DORSUM OF THE ILIUM. 

These comprise one-half of all hip dislocations, and are usually 
produced by some twisting movement of the body or limb when the 
latter is abducted, or from a crushing weight received when in a stoop- 
ing posture (Fig. 47). The symptoms are: The flexed position of the 
thigh, the knee, when the patient stands, projecting in front of but 
above the other; the rotation inward of the limb, the great toe resting 
on the instep of the opposite foot ; the projection of the great trochanter, 
and its approximation to the anterior-superior-spinous process of the 
ilium ; the elevation of the fold of the buttock ; the immobility of the 
limb, and the pain produced by any attempt to abduct or to extend it; 
and the marked shortening of the limb, from an inch and a half to two 
and a half inches. (Bryant.) 

DISLOCATION UPON THE FORAMEN OVALE, OR OBDURATOR FORAMEN. 

This is a very striking accident. Sedillot, as well as Boyer, be- 
lieves that it is the most common of all forms. In Bryant's table it 
stands second. It is generally caused by some forced abduction of the 



810 Dislocations, 

knee or foot, the head of the bone being tilted inward. It is char- 
acterized by the bent position of the body, and the pointing of the foot 
forward and slightly outward, the approximation of the trochanter 
towards the mesial line and consequent flattening of the hip, hollow- 
ness below the anterior-superior-spinous process of the ilium, the 
absence of the gluteal fold, and the elongation of the limb from one to 
two inches. Any attempt at movement causes pain. The head of the 
bone can be felt in its new position beneath the adductor muscles. 

Diagnosis. — The diagnosis from intracapsular fracture is obtained 
by noting the inversion, the great shortening, the absence of crepitus, 
the age of the subject, and the nature of the force. The nature of the 
force, the inversion, and the absence of crepitus mark the diagnosis 
from extracapsular fracture. 

Treatment. — Bigelow states: "The obstacle to reduction in dislo- 
cation on to the dorsum of the ilium, is the untorn portion of the 
capsule, especially the V-ligament. The ilio-femoral, V, or Bigelow's 
ligament, resembles an inverted V, arises from an interior inferior 
spine of the ilium, is inserted into the anterior intertrochanteric line, 
and is incorporated into the front of the capsule. To reduce a dislo- 
cation, this ligament must be relaxed by manipulation or be torn by 
extension. Manipulation makes the head of the bone retrace its steps 
over the same route it took in emerging. Give ether ; place the patient 
supine upon a mattress on the floor; flex the leg on the thigh to relax 
the hamstrings, the thigh on the pelvis ; increase the adduction over the 
middle line ; strongly abduct ; perform external rotation and extension. 
This treatment may be summed up as flexion, adduction, external cir- 
cumduction, and extension, or, as Pick puts it, 'Bend up, roll out, turn 
out, and extend.' If manipulation fails, try extension. A perineal 
band is fastened to the wall, and extension by pulleys is made in the 
axis of the deformed limb, that is, across the lower third of the other 
thigh (Fig. 48), or a right angle to the body, while the patient lies upon 
the sound side. After reduction, put the patient to bed, and use sand- 
bags (as in fracture of the hip) for four weeks. Passive motion is 
made in the third week." 

DISLOCATION INTO THE SCIATIC NOTCH. 

The head of the bone passes backward and a little upward, and 
rests upon the ischium at the margin of the sciatic notch (not in the 
notch), below the tendon of the obtnrator-internus muscle. The causes 
are the same as those given for previous dislocation. 

Symptoms. — There are flattening and broadening of the hip; 
ascent of the trochanter above Nelaton's line, shortening to the extent 
of an inch, flexion, inward rotation, and adduction exist ; but the axis 
of the femur of the injured side passes through the knee of the sound 
side, and the ball of the great toe of the injured side rests upon the 
great toe of the sound side (Fig. 49). Other symptoms are identical 



Dislocations. 811 

with dislocation upon dorsum of the ilium, but are less pronounced. 
Allis' signs of this dislocation are of value. If, with the patient 
recumbent, the thighs are brought to a right angle with the body, 
shortening on the affected side is materially increased ; if the dislocated 
thigh is extended, the back arches as in hip-disease. 

Treatment. — The treatment is the same as for dislocation back- 
ward upon the dorsum of the ilium (Fig. 50). 

DOWNWARD DISLOCATION INTO THE OBTURATOR FORAMEN. 

"This is the primary position of most dislocations of the hip, the 
bone rarely remaining in the thyroid foramen, but usually mounting up 
as a result of muscular action or the initial violence. The cause is 
violent abduction by falls or by stepping from a moving car. 

"Symptoms. — Dislocation downward into the obturator foramen 
is indicated by flattening of the hip. The head of the bone is felt in its 
new position, and is missed from the acetabulum; rigidity except in 
the direction of deformity; a hollow over the great trochanter, which 
process is well below Xelaton's line, and nearer the normal to the 
middle line ; the gluteal crease is lower than is the crease of the oppo- 
site side ; lengthening to the extent of one to two inches ; the body is 
bent forward by traction upon the psoas and iliacus muscles, and is 
also deviated to the side, thus causing great apparent lengthening. 
The limb is advanced and abducted, and the foot is pointed straight 
ahead or is a little everted (Fig. 51). When the patient is recumbent, 
extension is impossible, the knees can not be pushed together without 
great pain, and the adductor muscles are hard and rigid. Unreduced 
dislocations do well, the patient obtaining a very useful hip-joint." 
(Sedillot.) 

Treatment. — In treating dislocation downward into the obturator 
foramen, effect reduction, if possible, by manipulation, and if this fails, 
by extension. To reduce by manipulation, flex the leg on the thigh 
and the thigh on the pelvis, and then perform in the following order, 
abduction, internal circumduction, and extension. If extension is 
used, employ a pelvic band to pull the pelvis toward the sound side, 
and a perineal band beneath the pelvic band, having pulleys to main- 
tain force upward and outward from the injured hip. The surgeon, 
grasping the leg and ankle, drags the member inward, and pries the 
femur into place (Fig. 52). The after-treatment is the same as that 
for the previous forms. 

Symptoms of Pubic Dislocation. — The head of the bone can be 
felt and seen in its new position ; the hip is flattened ; there is a hollow 
over the great trochanter, this process being found below the anterior 
superior spine of the ilium; there is shortening to the extent of an 
inch; the limb is in abduction with eversion (Fig. 53), and the knees 
can not be aproximated without great pain. 

Treatment. — The treatment of pubic dislocation is manipulation, 
as performed for thyroid dislocation. The limb is well abducted, 



812 



Dislocations. 



extension is made downward and backward, and the head of the feimir 
is pulled outward by a towel around the thigh, just beneath the groin 




Fig. 47. — Hip-joint 
Dislocation: Upward, 
or on the Dorsum of 
the Ilium. (Cooper.) 




Fig. 51. — Hip-joint 
Dislocation: Down- 
ward, into the Obtu- 
rator or Thyroid 
Foramen. ( Cooper. ) 




Fig. 48. — Reduction of Dislocation en 
the Dorsum of the Ilium by the Pulleys. 
(Cooper.) 




Fig. 50. — Reduction of Dislocation into 
the Sciatic Notch by the Pulleys. (Cooper.) 




Fig. 52. — Reduction of Dislocation into 
the Obturator Foramen by the Pulleys. 
(Cooper.) 





Fig. 49. — Hip-joint 
Dislocation: B ack- 
ward, or into the Sci- 
atic Notch. (Cooper.) 




Fig. 58. — Dislocation 
onthePubes. (Cooper.) 



Fig. 54. — Reduction of Dislocation on 
the Pubes by the Pulleys. (Cooper.) 



(Fig. 54; Cooper), 
previous forms. 



The after-treatment is the same as that for the 



Dislocations. 813 

DISLOCATIONS OF THE KNEE. 

There are four forms, — forward, backward, inward, and outward. 
They may be complete or incomplete ; the most common dislocations 
are # lateral. The cause is violent force, such as a fall, or in jumping 
from a moving train, or in being caught by the foot and dragged. 

Diagnosis. — When the popliteal artery or vein is injured or rup- 
tured, amputation of the limb may be called for, this necessity being 
rendered more than probable when the circulation through the vessels 
is not speedily restored after the reduction of the dislocation, or when 
a swollen condition of the limb remains. 

Treatment. — These dislocations are readily diagnosed by the 
peculiar deformity they display, and are easily reduced by extension 
and the application of pressure where pressure is needed. After the 
parts have been replaced in their normal position, splints should be 
adjusted and cold applied, for secondary inflammation is almost sure 
to follow. In some cases fracture coexists, and in exceptional exam- 
ples, where the end of the diaphysis projects through the soft parts, its 
resection may be required to allow of its reduction. (Bryant.) 

DISLOCATION OF THE HEAD OF THE FIBULA. 

This accident is sometimes met with. Its nature can be readily 
recognized by the projection of the bone. It should be treated by the 
application of a pad and pressure over the part sufficient to keep the 
bone in its place, the limb being flexed when necessary, to relax the 
biceps femoris muscles. The pressure should be maintained for at 
least two months if good success is to be looked for. As a rule, the 
bone never quite resumes its former position, the head projecting more 
than usual. "This deformity, however, does not appear to weaken 
the limb to any great extent." 

Dislocation of the Interarticvlar Fihro-cartilages {Semilunar). — 
This is a recognized accident. It is produced by some sudden twist 
of the knee with the foot everted,, and generally in subjects who have 
relaxed joints or such as have been the seat of some chronic synovitis. 
The inner cartilage seems more liable to displacement than the outer. 

Symptoms. — The symptoms of the accident are well marked. A 
patient when walking, accidentally catches his foot against a stone, or 
in rising from a kneeling position is seized with a sudden sharp, 
sickening pain in the knee; the joint becomes at once fixed in a semi- 
flexed position, and any attempt to move it only excites some pain. 
When the first pain has subsided, a painful spot is usually left, where 
the projecting cartilage may be felt, or even seen ; and if the "internal 
derangement of the joint," as it was originally called, is left untreated, 
synovitis or effusion into the joint will soon show itself. 

Treatment. — "The best practise consists in the forced flexion of 
the joint, the slight rotation of the leg outward, and sudden exten- 
sion, pressure with the thumb upon the cartilage above the edge of 



814 Dislocations. 

the inner condyle of the tibia during the flexion and extension often 
being of use. When success attends this maneuver, the joint moves 
smoothlv and without pain, and the patient will at once be able to 
move the joint freely. After its reduction, the joint should be kept 
in a splint, and such means employed as the symptoms that follow 
indicate; for more or less inflammation often ensues, requiring ice, 
cold lotions, leeching, and rest. When active symptoms have sub- 
sided, it is well to restrain the movements of the joint by means of a 
knee-cap or strapping, as a recurrence of the accident is liable to 
follow upon the least occasion. 

"Dislocations of the Ankle-joint. — Such an accident uncomplicated 
with rupture is rare; that is, dislocation of the foot outward is gen- 
erally associated with fracture of the fibula, and dislocation inward 
with fracture of the tibia, or both malleoli may be broken. However, 
pure dislocation of the foot forward or backward may occur. 

"Treatment. — The lateral displacements of the foot are not diffi- 
cult of reduction by extension and well-directed manipulative force. 
The flexion of the knee facilitates this operation by relaxing the 
muscles of the calf. 

a To keep the bones in position, a flat posterior splint extending 
up to the popliteal space, with foot-piece and two side splints, all well 
padded, are, as a rule, sufficient, the surgeon using his judgment as to 
the amount of pressure and padding that may be demanded. In some 
cases where it is very difficult to keep the parts quiet, from the action 
of the gastrocnemii muscles, the tendo Achillis should be divided, the 
foot after this simple operation being perfectly passive and entirely in 
the hands of the surgeon to place and to keep in any required posi- 
tion." (Bryant) The limb should subsequently be slung in a proper 
swing, Salter's being the best. In hospital practise, two or more pieces 
of bandage slinging the splints to the cradle will answer well. In 
displacement of the foot forward or backward the same kind of treat- 
ment is applicable, but in these accidents it is expedient, as a rule, to 
divide the tendo Achillis at once.. This should be done at any rate 
when the slightest disposition to displacement is found to exist, the 
treatment of the case being by this operation rendered more simple 
and certain. 

The splints should be retained for at least six weeks, and after- 
ward passive movement should be allowed. The patient should not 
bear any weight on the limb for another month. 

Dislocation of the Tibia and Fibula at Their Lower Articulation, 
with a Forcing of the Astragalus Upward between the Two Bones. — 
This is an accident produced usually by a jump from a height on the 
foot or feet. This dislocation may be diagnosed from displacement at 
the ankle-joint and dislocation of the astragalus itself by the fact that 
extension and flexion are present; from fractures about the ankle by 
the absence of crepitus, together with the positive signs of the injuries 
themselves. 






Dislocations. 815 

Treatment. — Anesthetize the patient, and reduce by extension and 
manipulation. Success may be looked for. When difficulties are 
experienced, Turner's suggestion of dividing the tendo Achillis, or 
any other tendon when it is clearly interfering with replacement of 
the bones, should be followed. When these means fail, the case should 
be treated as one of a compound nature, and the astragalus is jrartially 
excised, the foot being subsequently well confined in splints, and ice 
applied. Occasionally amputation may be demanded. 

Dislocation of the Astragalus. — The astragalus may be displaced 
from the bones of the leg, and at the same time be separated from the 
rest of the tarsus. The displacement may be forward, backward, out- 
ward, inward, or rotary. Dislocation of the astragalus is caused by 
falls or twists. 

' Symptoms. — In forward dislocation the astragalus projects 
strongly; there is shortening of the foot, and the malleoli approach 
the plantar aspect of the foot ; the foot is deviated to one side or to the 
other, and there is absolute rigidity of the ankle-joint. In backward 
dislocation of the astragalus the foot is not deviated to either side; 
the astragalus projects between the malleoli and above the os calcis, 
and the tendo Achillis is stretched over the projection. Rigidity is 
absolute. 

Treatment. — In treating astragalus dislocation, reduce under ether 
by flexing the knee to relax the gastrocnemius muscle, extending the 
foot, and pushing the bone into place. It may be necessary to cut 
the tendo Achillis. After reduction, put up the foot and leg in 
silicate .of soda dressing for two weeks, and then begin passive motion 
and apply side splints, which are to be worn for one week more. 
If reduction fails, support the limb on splints, combat inflammation, 
and endeavor to bring about union between the dislocated bone and 
the tissues. Often in unreduced dislocation, the skin sloughs over 
the projecting bone. Excision is demanded the moment sloughing is 
seen to be inevitable. Cases of compound dislocation of the astraga- 
lus require immediate excision. <(Da Costa.) 

Dislocations of the Phalanges. — These are very rare. The first 
phalanx of the big toe is the one most liable to dislocation. 

Symptoms and Treatment. — Dislocations of the phalanges are 
obvious. The treatment is by reduction ; immobilize for two weeks. 



CHAPTEK LXV. 
FOODS AJSTD FOOD PKEPAKATIOK 

ELEMENTARY COMPOSITION OF FOOD (THOMPSON). 

Of the seventy-three chemical elements, thirteen enter uniformly 
into the composition of the body, and ten more are occasionally found. 
Qf all these, several exist in very small proportion, and their uses are 
unknown ; several are found more abundantly, but are not indispensable 
to life; and certain elements, namely, carbon, hydrogen, oxygen, and 
nitrogen, are necessary ingredients of tissues of the body. These ele- 
ments form compounds, which, as they occur in the structures of the 
various tissues, have the following characteristics: — 

First, although the elements are but few in number, their 
molecular arrangements are very complex. 

Second, their compounds are comparatively unstable, and are 
readily converted in the body or by chemical analysis into other forms. 

All foods are composed of combinations of these simpler chemical 
elements, which, for the most part, must be subjected to alteration in 
the body itself to prepare them for assimilation by the tissues. The 
nutrition of the body, therefore, involves several distinct processes, 
viz. : — 

1. The secretion of digested fluids, and their action upon food in 
the alimentary canal. 

2. The absorption of the ingredients of the food, when digested, 
into the blood and lymphatic vessels. 

3. The assimilation of the absorbed nutritious products by the 
tissues. 

4. The elimination of the waste material. 

The following analysis exhibits admirably the relative predom- 
inance of the elements of which the human body is composed : — 

APPROXIMATE ANALYSIS OF A MAN (MOSS). 

(Height, 5 feet 8 inches; weight, 148 pounds.) 

Oxygen 92.4 pounds 

Hydrogen 14.6 pounds 

Carbon 31.6 pounds 

Nitrogen 4.6 pounds 

Phosphorus 1.4 pounds 

Calcium 2.8 pounds 

Sulphur 24 pounds 

Chlorine 12 pounds 

(816) 



Foods and Food Preparation. 817 

Sodium 12 pounds 

Iron 02 pounds 

Potassium . . . . 34 pounds 

Magnesium 04 pounds 

Silica 2 pounds 

Fluorine 02 pounds 

Total 148.00 pounds 

All these elements are necessarily derived from food plus the 
oxygen of the air that we breathe. The three predominating elements 
— oxygen, hydrogen, and carbon— are the great force producers of the 
body, although they are tissue formers as well, and to them must be 
added nitrogen, as serving in this double capacity, although its rela- 
tion to tissue formation and renewal is greater than its capacity for 
supplying energy. 

The common elements which enter into tissue formation chiefly, 
and which bear no direct relation to the main sources of the force pro- 
duction in the body, are chlorine, sulphur, phosphorus, iron, sodium, 
potassium, calcium, and magnesium in different combinations. Bone 
tissue, for example, contains about fifty per cent of lime phosphate. 
If this substance is deficient in the food of the young, growing infant, 
the bones are poorly developed, and so soft that they yield to the strain 
of the weight of the body, and become bent and out of shape. This 
constitutes one of the principal symptoms of rickets. 

Lack of iron salts in the food impoverishes the coloring matter of 
the red blood-corpuscles, on which they depend for their power of carry- 
ing oxygen to the tissues, and anasmia and other disorders of deficient 
oxidation result. 

The lack of sufficient potash salts, especially potassium carbonate 
and chloride, is a factor in producing scurvy, and the condition is 
aggravated by the use of common salt (Nace). A diet of salt meat 
and starches may cause it, with absence of potatoes and fresh fruits and 
vegetables. 

The lack of sodium chloride interferes with many of the functions 
of the body immediately concerned with nutrition, such as absorption 
(osmosis), secretion, etc., and alters the density and reactions of the 
different fluids. 

These few illustrations suggest the diversity of roles exhibited by 
the elements, and the need for a correctly-balanced diet. In order to 
determine* what such a diet should consist of, it is necessary to study 
the value of the principal classes of foods in force production, and in 
nutrient power or tissue building; but before proceeding further with 
this discussion, it will be advisable to adopt a simple, comprehensive 
classification of the foods in general use by man. The following table 
of analyses, made by Dujardin-Beaumetz, is quoted by Yeo, to show 
the proportion of nitrogen present in different foods, and also the com- 
bustible carbon and hydrogen. 

52 



818 Foods and Food Preparation. 

"The hydrogen existing in the compound in excess of what is re- 
quired to form water with the oxygen present is calculated as carbon* 
It is only necessary to multiply the nitrogen by 6.5 to obtain the amount 
of dry proteids in 100 grams of the fresh food substance." 

C+H. Combustibles 
Calculated as 

Nitrogen. Carbon. 

Beef (uncooked) 3.00 11.00 

Eoast beef 3.53 17.76 

Calf's liver 3.09 15.68 

Soie-gras 2.12 65.58 

Sheep's kidneys 2.66 12.13 

Skate 3.83 12.25 

Cod, salted 5.02 16.00 

Herring, salted 3.11 23.00 

Herring, fresh 1.83 21.00 

Whiting 2.41 9.00 

Mackerel 3.74 19.26 

Sole 1.91 12.25 

Salmon 2.09 16.00 

Carp 3.49 12.10 

Oysters 2.13 7.18 

Lobster (uncooked) 2.93 10.96 

Eggs 1.90 13.50 

Milk (cow's) 0.66 8.00 

Cheese (Brie) 2.93 35.00 

Cheese (Gruyere) 5.00 38.00 

Cheese (Koquefort) 4.21 44.44 

Chocolate 1.52 58.00 

Wheat (hard southern, variable, aver- 
age) 3.00 41.00 

Wheat (soft southern, variable, aver- 
age) 1.81 39.00 

Flour, white (Paris) 1.64 38.50 

Bye flour 1.75 41.00 

Winter barley 1.70 44.00 

Maize 2.20 42.50 

Buckwheat 1.80 41.00 

Kice 1.95 44.00 

Oatmeal 1.08 29.50 

Bread, white (Paris, 30 per cent 

water) : 1.07 28.00 

Bread, brown (soldiers' rations for- 
merly) 1.20 30.00 

Bread, brown (soldiers' rations at 

present) 1.20 30.00 

Bread from flour of hard wheat. . . 2.20 31.00 

Potatoes 0.33 11.00 



Foods and Food Preparation. 819 

Beans 4.50 4,02 

Haricots (dry) 3.92 43.00 

Lentils (dry) 3.87 43.00 

Peas (dry) 3.66 44.00 

Carrots 0.31 5.00 

Mushrooms 0.60 4.50 

Figs (fresh) 0.41 15.50 

Figs (dry) 0.92 34.00 

Coffee (infusion of 100 grams) 1.10 9.00 

Tea (infusion of 100 grams) 1.00 10.50 

Bacon 1.29 71.14 

Butter (fresh) 0.64 83.00 

Olive-oil Trace 98.00 

Beer, strong 0.05 4.50 

Wine 0.15 4.00 

To estimate the equivalent chemical elements in the different 
classes of food, Parker gives the following simple rules: — 

1. To obtain the amount of nitrogen in proteid foods, divide the 
quantity of food by 6.30. 

2. To obtain the carbon in fat, multiply by .79. 

3. To obtain the carbon in carbohydrate foods, multiply by .444. 

4. To obtain the carbon in proteid foods, multiply by .535. 

Estimates vary somewhat as to the average quantity of the ele- 
ments — carbon and nitrogen — consumed per diem. In a general way 
it may be said that the consumption of carbon is 320 grams, and that 
of nitrogen about 20 grams. 

The quantity of food required to maintain the body in vigor de- 
pends upon the following conditions: — 

(1) External temperature; (2) climate and season; (3) clothing; 
(4) occupation, work, and exercise; (5) the state of individual health; 
(6) age; (7) sex. 

In civilized communities, where cooking is a fine art, the variety of 
food preparations is so great that the appetite is often stimulated be- 
yond the requirements of the system, and consequently more food is 
eaten than is necessary or desirable to maintain the best standard of 
bodily health and vigor. 

Persons in this country who live in comfortable circumstances, 
often eat a dozen or fifteen ounces of solid food at breakfast, and again 
at luncheon, and perhaps thirty ounces more at dinner, making a total of, 
say, fifty-five or sixty ounces, to which are added only fifty or fifty-five 
ounces of fluids. This is about a third more than the amount of solids 
actually needed, forty ounces of solid food (which equals twenty-three 
ounces of water-free food) being a fair average for the daily necessi- 
ties of most persons, one-fourth of which should be animal and three- 
fourths vegetable food. People eat too much, and drink too little fluid 
in proportion. 



820 Foods and Food Preparation. 

Water, estimated as a force producer within the body, may be 
said to have comparatively little value. Much of the water which is 
either drunk or ingested in combination with foods passes through the 
body unchanged, and is eliminated from one or more of the excreting 
surfaces ; but some of it is undoubtedly altered or split up into elements 
which unite with other compounds. The nature of these processes is 
obscure, and as yet very little understood. It is believed, also, that a 
certain quantity of water is produced in the body by the union of oxygen 
and hydrogen, which occurs incident to other chemical change, or by the 
liberation of water from more complex molecules. Water is entitled 
to rank as a food, because it enters into the structural composition of all 
^he tissues of the body, and, in fact, constitutes rather more than two- 
thirds (70 per cent) of the entire body weight. Its importance is 
readily appreciated after it has been withheld from the diet for a 
short time, when striking physical and physiological alterations in the 
functions of the body occur. 

Yeo says that "assuming the water-free food to be 23 ounces, and 
a man's weight to be 150 pounds, each pound weight of the body re- 
ceives in twenty-four hours .15 ounces, or the whole body receives 
nearly a hundredth part of its own weight. But ordinary solid food 
contains usually between 58 and 60 per cent of water ; and if we add 
this to the water-free solids, the total daily amount of so-called dry 
food (exclusive of liquids) is about 48 to 60 ounces. But from 50 to 
80 ounces of water in the liquid form is usually taken in addition, and 
this would make the total supply of water equal 70 to 90 ounces, or 
half an ounce for each pound of body weight." 

Gluttony results in overdevelopment and overwork of the digestive 
apparatus. The stomach and bowels become enlarged, the liver is 
engorged, and a predisposition is established to degenerative changes, 
fatty heart, etc. 

Overeating and overdrinking may both be, first, temporary, that 
is, the result of an occasional debauch; or, second, chronic. 

Temporary overeating may apply to the excessive consumption of 
a mixed diet, or of a particular article of food. The former causes 
dyspepsia, or, in extreme cases, acute gastro-enteritis. The latter may 
also cause dyspepsia and diarrhea, or such affections may be produced 
as glycosuria, from excessive indulgence in candy and sweets; acne 
and other skin diseases, from the too liberal consumption of fats. 

Temporary overeating at one or two meals may not produce any 
serious effect, but if the excess in feeding be long continued, a variety 
of ills results, attributable directly to the overloading of the alimentary 
canal, and to the accumulation of waste matter in the tissues, and conse- 
quent imperfect oxidation processes. 

The excess of food may be injurious in one or two ways: — 

First, if it is not absorbed, it ferments abnormally in the ali- 
mentary canal. There is a limit to the quantity of every food which 






Foods and Food Preparation. 821 

can be digested in a given time ; beyond this, the food, whether starches, 
fats, sugar, or proteids, may decompose, or pass away unaltered. 

Second, if the excess is absorbed, the blood is overwhelmed, and the 
excretory organs are overworked. 

Chronic overeating may cause such diseases or diatheses as obesity, 
gout, lithemia, oxaluria, and the formation of renal, vesical, and 
hepatic calculi. It is very certain to cause congestion of the liver, and 
the condition known as biliousness, in which the stomach and intestines 
are engorged ; constipation results ; the tongue is heavily coated ; the 
bodily secretions are altered in composition, the urine especially becom- 
ing overloaded with salts ; the liver becomes congested ; and finally the 
nerves and muscular system are affected, with, as a result, headache and 
feelings of fatigue, lassitude, drowsiness, and mental stupor. 

For persons leading sedentary lives, the excessive consumption of 
animal food is said to be more injurious than vegetable food, for the 
reasons given above, although obesity is more likely to result from 
excess in a vegetable diet and sweets. The nitrogenous foods, requir- 
ing, as they do, a large consumption of oxygen for their complete com- 
bustion and reduction to urea and allied products, produce forms of 
waste matter in the system which are more deleterious than carbo- 
hydrates, that are converted into water and carbonic acid, and are more 
easily eliminated. It is for this reason that defective nitrogenous 
metabolism alters the composition of the blood, and paves the way for 
disorders of nutrition, such as lithiasis. 

The presence of intestinal round-worms and tapeworms may give 
rise to overeating, though this by no means always follows. 

Overeating not only taxes the digestive system, but, what is often 
more serious, it throws too great a strain upon the glandular and excre- 
tory organs, especially the liver and kidneys, and if the habit is long 
continued, disease of the nature above described inevitably results. 
Overeating, especially among the well-to-do, is the commonest dietetic 
error, and, looking at the question in its broadest aspects, it is quite 
certain that the foundation for more disease is laid by this habit than 
by overdrinking. The former, indeed, sometimes conduces to the lat- 
ter, and there are some examples of alcoholism in which desire for 
drink is only aroused and fostered by previous excesses in eating. 

Overdrinking, except of alcohol, is not common, and is mainly 
confined to the excessive consumption of tea and coffee, which results 
in insomnia, cardiac palpitation, and various neuroses in some cases. 
Dilatation of the stomach has been attributed in some cases to over- 
indulgence in mineral waters, but such instances are very unusual. 
Excessive use of milk as a beverage usually results in biliousness and 
constipation, for the reason that it is really a solid food, that is, it 
becomes such immediately on entering the stomach. Thirst is often 
extreme in fevers, diabetes, and other conditions; but the drinking of 
exceptionally large quantities of water is by no means always harmful, 
and it is often desirable to recommend it as a diluent and diuretic. 



822 Foods and Food Preparation. 



FOOD CLASSIFICATION. 



Foods are classed in accordance with their general physical prop- 
erties, first, into solid, semisolid, and liquid foods; secondly, into 
fibrous, gelatinous, starchy, oleaginous, and albuminous foods. 

A subdivision sometimes used is that of the "complete" foods, such 
as eggs and milk, which in a single article comprise all the necessary 
ingredients and elements to support life ; and "incomplete" foods, which 
are capable of maintaining life but a comparatively short time. 

Foods may be classed as to their source, primarily into animal 
and vegetable foods. Animal food consists of meat, fowl, fish, shell- 
fish, and crustaceans, eggs, milk, and its products, and animal fats. 
The vegetable foods are subdivided into cereals, vegetables proper, 
fruits, sugars, vegetable oils. 

The simplest chemical classification possible is that advocated by 
Baron von Liebig, who was the first to suggest a really scientific divi- 
sion of foods. He grouped all foods into two classes, (a) nitrogenous ; 
(b) non-nitrogenous. 

Each of these classes contains food material derived from both the 
animal and the vegetable kingdom, although the majority of the ani- 
mal substances belong to the nitrogenous, and the majority of vegetable 
substances to the non-nitrogenous group. 

(a) The nitrogenous group Yon Liebig regarded as containing 
plastic elements, i. e., they are essentially tissue builders or flesh 
formers. 

Nitrogenous foods are sometimes called "ozonized" foods, or 
albuminoids, that is, substances resembling albumin. They consist 
chiefly of the four elements, — carbon, oxygen, hydrogen, and nitro- 
gen, — to which a small proportion of sulphur and phosphorus are usu- 
ally joined. These elements for the most part are combined as some 
form of albumen. 

Nitrogenous or proteid foods are non-cry stallizable, but coagulable, 
principally fluid or semisolid substances. They are fermentable, and 
under some conditions will putrefy. 

The nitrogenous group comprises all forms of animal food, except 
fats and glycogen. It includes, therefore, albuminoids and gela- 
tins. Its chief representatives are milk, eggs, crustaceans, fish, shell- 
fish, flesh, and fowls. It also contains such nitrogenous substances as 
occur in the vegetable kingdom, or vegetable albuminoids. 

(&) The second, or non-nitrogenous group, Yon Liebig calls 
"respiratory or calorifacient foods," because their function in the body 
is to furnish the fuel, or maintain animal heat. Since this original 
classification was suggested, it has been established that the non- 
nitrogenous aliments supply energy as force, manifested through mus- 
cular action ; hence they are also called "force producers," in distinc- 
tion from the nitrogenous tissue formers. 

This is a convenient distinction to adopt, but it must not be held 
too absolutely ; for in emergencies the tissue builders are used as force 
producers and heat givers as well. 



Foods and Food Preparation. 



823 



The non-nitrogenous group contains, strictly, only the three ele- 
ments — carbon, hydrogen, and oxygen — although various salts are 
mixed with both vegetable and animal foods. It includes all forms of 
vegetables and fruits, cereals, starches, sugars, gums, fats, and oils, 
which are both animal and vegetable, and also organic acids. Many 
vegetables, and some fruits, contain considerable nitrogen. Many of 
the vegetables, and, in fact, all the starch granules, contain a proportion 
of nitrogenous material, which is chiefly used in the formation of out- 
side covering, whose purpose is to give protection, and afford firmness 
of resistance, to a softer pulp within. 

Neither is animal food, on account of its fat and glycogen, strictly 
nitrogenous ; nor is vegetable food, owing to its albuminoids and other 
forms of proteids, strictly non-nitrogenous; yet this classification is a 
very convenient and simple one, and has met with general acceptance. 
It will be used in this chapter, with the understanding that it has only 
a general and not too literal application ; and, unless otherwise distinctly 
specified, "nitrogenous food" will be understood to include animal food, 
and "non-nitrogenous food" to include vegetable foods of all kinds. 

TABLE OF COMPOSITION OF SOME COMMON FOODS. 

(H of man.) 





Nitrogenous 
Constituents. 


Pat. 


Carbohy- 
drates. 


Salt. 


Total. 


Fat beef. 


51.4 

89.4 
27.3 
16.6 

7.7 


45.6 

5.5 

.8 

.9 

.4 


68.9 
81.9 
91.2 


3.0 
5.1 
3.0 

.6 

.7 


100 


Lean beef. 

Pea flour. 

Wheat 

Eice 


100 
100 
100 
100 



TABLE OF COMPOSITION OF COMMON FOODS. 

{From Parker.) 



Articles. 


Water. 


Proteids. 


Fats. 


Carbohy- 
drates. 


Salts. 


Beefsteak 


74.4 

39.0 
27.8 
78,0 
74.0 
4(..0 

8.0 
15.0 
13.5 
13.1 
15.4 
15.0 
74.0 
85.0 
91.0 

6.0 
73.5 
36.8 
86.8 
66.0 
88.0 

3.0 


20.5 

9.8 

24.0 

18.1 

21.0 

8.0 

15.6 

12.6 

10.6 

9.6 

.8 

22.0 

2.0 

1.6 

1.8 

:3 

13.5 

33.5 

4.0 

2.7 

4.0 


3.5 

48.9 

36.5 

2.9 

3 8 

1.5 

1.3 

5.6 

6.7 

.3 

*2.6 
.16 
.25 

5.0 
91.0 
11.6 
24.3 

3.7 
26.7 

1.8 


'49.2' 
73.4 
63.0 
64.5 
76.8 
83.3 
53.0 
21.0 
8.4 
5.8 

r 4.8' 
2.8 
5.4 

96.5 


1.6 


Fat pork 


2.3 


Smoked ham 


10.1 


White fish 


1.0 


Poultry 


1.2 


White wheat bread 

Biscuit 

Oatmeal 


1.3 

1.7 
3.0 


Maize , 


1.4 


Macaroni 


.8 


Arowroot 

Pear (dry) 


.27 
2.4 


Potatoes 


1.0 


Carrots 

Cabbages 

Butter 

E££S (At for shell) 


1.0 

.7 

2.7 

1.0 


Cheese. 

Milk (specific gravity 1032) 

Cream 

Skimmed milk 


5.4 

.7 

i.a 

.8 


Sugar 


.5 



CHAPTER LXVI. 
FORCE PRODUCTION— ENERGY FROM FOOD. 

The two ultimate uses of all foods are to supply the body with 
material for growth or renewal, and with energy, or the capacity for 
doing work. The energy received in a latent form, stored in the various 
chemical combinations of foods, is liberated as kinetic or active energy 
in two chief forms : first, as heat ; second, as motion. Force is the mani- 
festation of energy. The force developed by a healthy adult man at 
ordinary labor averages 3.400 foot-tons per diem, a foot-ton being the 
amount of force required to raise a weight of one ton to the height 
of one foot. Of this, somewhat less than one-fifth is expended in 
motion, and somewhat more than four-fifths, or 2.840 foot-tons, in heat, 
which maintains the body temperature at its normal average. 

A man weighing one hundred and fifty pounds, or over one- 
thirteenth of a ton, obviously expends considerable energy in merely 
moving his own body about from place to place, aside from carrying any 
additional burden. 

The original force developed in the various functions of animal 
life, which results in heat production and motion, is chiefly obtained 
from the radiant heat of the sun stored by plants in the latent form of 
certain chemical compounds — chiefly starches and sugars — which, on 
being consumed as food by animals, furnish energy. 

A useful comparison is made by Thompson between the processes 
of nutrition and development of energy in the human body, and the 
energy derived from a steam engine and boiler. In both cases, the 
source of energy is oxidation, and principally of carbon. In both cases, 
the latent energy of the carbon, liberated by oxidizing processes, is con- 
verted into heat and motion, forms of energy which bear a definite 
relation to each other. 

If a large part of the original latent energy is converted into heat, 
less will yield motion, and conversely. The proportion of these two 
forces to each other is, in the case of the most perfectly constructed 
engine, about one of motion to eight of heat; whereas in the human 
body it was calculated by Helmholtz "that the motion obtainable from 
a given amount of food may stand in relation to the heat in proportion 
of one to five. Hence, as regards the production of work through 
motion, the human body is a more perfectly constructed machine than 
the engine. Furthermore, after combustion of the carbon by the fires of 
the boiler, a certain amount of waste matter, or ashes, is produced. If 
this is allowed to accumulate, it obstructs the draught, and interferes 

(824) 



Force Production — Energy from Food. 825 

with active oxidation. In the human body, in like manner, the fuel, 
or food, consumed, produces ashes, such as urea and other forms of 
waste material, which, if not removed, accumulate in the system, and 
embarrass or retard the normal oxidation processes. The body pos- 
sesses the additional power of sorting and modifying the fuel food which 
it receives, so as to develop its energy to the best advantage in different 
organs. 

"Whether elementary substances are burned outside of the body, 
or oxidized within the body, the resulting products are the same. There 
can be no loss of matter, and there can be no loss of energy. The mat- 
ter is changed in form by molecular rearrangement ; the energy is con- 
verted from one type into another. The following simple experiment 
will illustrate this point: In a large covered glass jar place an ounce 
of alcohol in a small metal vessel. Also place in the jar a little lime- 
water in a tumbler, and a thermometer. On igniting the alcohol and 
allowing it to burn away completely, a film of aqueous vapor will accumu- 
late on the surface of the jar, and a film of calcium carbonate will form 
on the surface of the lime-water, produced by the union of carbonic-acid 
gas with the lime-water. The thermometer will indicate a rise in tem- 
perature of the air in the jar. An ounce of alcohol consumed as food 
will be similarly converted into carbonic-acid gas and water, and in the 
process in the body, heat will be increased." ^To substance is a good 
food unless it fulfils two conditions, viz., easy assimilation and complete 
combustion. 

The relative importance of the different food fuels should be con- 
sidered. This is well summarized by Woodruff : — 

"For instance, cut off the supply of oxygen, and death ensues in 
from one to ten minutes. If water is withheld, preventing the trans- 
portation of the fuel and oxygen to various parts of the body, death 
follows in about two to seven days or more, according to climate, 
exposure, and exercise. If the fuel itself is taken away, death follows 
in from seven to forty days or more, according to the amount of 
exposure that would abstract heat and the amount of work that would 
use up the energy already stored up in the body. If material for the 
repair of tissue be excluded, death follows in a variable time, dependent 
upon the importance of the tissue that is being starved — a time varying 
from a week, if all nitrogen is excluded, to several months if the vege- 
table acids are excluded, or even to several years if certain more obscure, 
substances are withheld. It still remains extremely difficult in the case 
of all foods to trace their final uses in the body, and determine with any 
approach to accuracy what proportions of each furnish respectively 
energy, repair of tissue, and heat ; for there are no more complex chem- 
ical processes known than those of tissue metabolism." 

STIMULATING FOODS. 

In the broadest sense, all food is stimulating to the functional 
activity of the body; but when the digestive and assimilative powers 



826 Force Production — Energy from Food. 

are lowered, less variety and less quantity of food can be tolerated, 
and foods that in health are never needed may become necessities; 
such foods, for example, are cod-liver oil, and the various prepara- 
tions of meat, such as albumoses, peptones, meat juice, etc. 

Certain food substances have a distinctly stimulating action at 
all times. The various condiments possess a local action of this kind 
upon the alimentary organs, but not a general or systemic action. The 
latter stimulation, manifested especially upon the nerve muscular 
apparatus, is derived from such substances as strong beef extracts, 
coffee, tea, and alcohol, all of which at times are of great service in 
the dietetic treatment of disease. 
t 

ECONOMIC VALUE OF FOOD. 

We will not discuss the details of the economic value of foods, 
but brief reference to one or two facts will emphasize the importance 
of this topic. 

The economic value of food is by no means to be estimated exclu- 
sively from its weight, and, as suggested by Williams, a pound of 
biscuit may contain more actual force-producing material than a pound 
of beefsteak, and yet the body may be able to assimilate more of the 
beefsteak and derive more energy therefrom; and it is the chemical 
processes of nature which convert such substances as grass, which are 
not assimilable by the human organism, into the flesh of the ox, which 
is readily digested by man. 

It is economical for contractors employing large bodies of men 
in manual labor to see that they are well fed; for much more work, 
proportionately, will then be got from them. 

Carbohydrates check albuminous waste and, like fats, yield both 
heat and mechanical work; hence good bread, sugar, and vegetables 
are all economical foods for the laborer. Unlike the other classes of 
foods, however, they do not produce muscle, and do not enter into 
the actual structure of the tissues to any great extent, although the 
carbohydrates may be found existing as glycogen in some of the tis- 
sues, like the muscles and liver. In general, they are said to be more 
easily metabolized than fats or proteids. 

The following tables give a fair conception of the economic value 
of common foods in relation to their waste residue and capacity for 
producing work: — 



Force Production — Energy from Food. 



827 



THE RELATIVE VALUE OF FOODS. 

(Scammell.) 

[The- figures represent percentage.) 



Articles. 


As Materi- 
al for the 
Muscles. 


As Heat 
Gtyers. 


As Food for 
Brain and 

Nervous 
System. 


Water. 


Waste. 


Wheat 


14.6 

12.8 

17 

12 3 

34.6 

8.6 

6.5 

24.0 

23.4 

26.0 

5.1 

1.4 

1.5 

2.1 

1.2 

1.1 

1.2 

3.6 

0.1 

5.0 

3.0 

17.7 

19.0 

19.6 

21.0 

17 5 

21.6 

16.5 

16.9 

17.0 

20.0 

17 

18.0 

18.0 

12.6 

12.0 

14.0 

13.0 

"l'.9 
0.6 
8.4 
18.0 
30.8 
0.6 
8.8 
3.5 
0.9 

To 

35.0 

01 

21.2 

25.3 


66.4 
52.1 
50.8 
67.5 
39.2 
53.0 
75.2 
40.0 
41.0 
39.0 
820 
15.8 
21.8 
14.5 

4.0 
12.2 

6.2 

4.6 

1.7 

8.0 

7.0 
14.3 
14 
14.3 
14.0 
16.0 

1.9 

1.0 

0.8 

Very little 

Some fat 

(< 

u 

Very little 
cc 

29:8 

100.0 
19.0 

5.4 
62.5 

0.8 
28.0 
21.0 
88.0 

4.5 

6.8 
73.7 
57.9 
32.0 

4.8 

0.9 
100.0 

3.9 


1.6 
4.2 
3.0 
1.1 
4.1 
1.8 
0.5 
3.5 
2.5 
1.5 
0.5 
0.9 
2.9 
1.0 
0.5 
1.0 
0.8 
1.0 
0.5 
1.0 
0.5 
2.3 
2.0 
2.2 
2.0 
2.2 
2.8 
2.5 
4.3 

5 or 6 

6 or 7 

3 or 4 

4 or 5 
3 or 4 

0.2 
2 or 3 

5 or 6 
2.8 
2.0 

1.8 
0.4 
0.5 
2.9 

4.7 
1.0 
1.8 

"0.3 

3.4 

4.4 
1.0 
1.4 

"l.2 


14.0 
14.0 
13.6 
140 
14.0 
14.2 
13.5 
14.8 
14.1 
14.0 
9.0 
74.8 
67.5 
79.4 
90.4 
82.5 
91.3 
90.0 
97.1 
86.0 
89.5 
65.7 
65.0 
63.9 
63.0 
64.3 
73.7 
80.0 
78.0 
75.0 
74.0 
75.0 
75.0 
74 
87.2 

79.0 
84.2 
51.3 

76.6 
93.6 
28.6 
78.3 
36.5 
76.3 

92.0 

81.3 
24.0 

18.7 
28.6 
78.2 
76.5 

68.6 


3.4 


Barley 


16.9 


Oats 


16.9 


Northern corn 

Southern corn... 


5.1 
8.1 


Buckwheat 


22.4 


Rve 


4.3 


Beans 


17.7 


Peas 


19.0 


Lentils 

Rice 

Potatoes 


19.5 
3.4 
7.1 


Sweet potatoes 

Parsnips 

Turnips 


6.3 
3.0 
3.9 


Carrots 


3.2 


Cabbage 


0.5 


Cauliflower 


0.8 


Cucumber 


0.6 






Milk of human 








Beef 




Mutton 

Pork 

Chicken 




Codfish 




Trout 

Smelt 




Salmon 

Eels 




Herring 




Oysters 








Lobsters. 








Eggs (yolks of) 

Artichokes 


0.7 






Bacon 




Carp 

Cheese 




Chocolate 


1.1 

1.4 


Currants 

Figs 


10.7 

2.3 

15.0 


Horseradish 


16.0 


Kidneys 

Lard 

Liver 





828 



Force Production — Energy from Food. 



Articles. 


As Materi- 
al FOR THE 

Muscles. 


As Heat 
Givers. 


As Food for 
Brain and 

Nervous 
System. 


Water. 


Waste. 


Onions 

Pearl barley 


0.5 
4.7 
0.1 
23.0 
8.9 
1.2 

20.4 

47.5 


5.2 
78.0 

9.6 

1.9 
78.6 

7.4 
100.0 

8.0 
38.0 

4.6 


0.5 
0.2 

"2.7 

4.5 
1.0 

"2.8 

1.7 
0.7 


93.8 
9.5 
86.4 
72.4 
13.0 
89.1 

68.8 

12.8 
94.7 


7 6 


Pears 

Pigeons 

Prunes 

Radishes 


3.9 
1.3 


Suet 




Venison 

Vermicelli „ 




Whey 

4. 





ATKINSON S TABLE OF DIGESTIBILITY OF NUTRIENTS OF FOOD MATERIAL. 

In the food materials below of the total amounts of protein, fats, 
and carbohydrates the following percentages were digested: — 



Material. 


Protein. 


Fats. 


Carbohy- 
drates. 


Meat and fish 


Practically all 
88 to 100 


79 to 92 

96 
93 to 98 

98 

96 

9 
? 
? 

? 
? 

? 




Eggs 




Milk 

Butter 


—j" 


Oleomargarine 

Wheat bread 






81 to 100 
89 

84 
86 
74 
72 


99 


Cornmeal 


97 


Rice.. 

Peas 

Potatoes 


99 
96 
92 


Beets 


82 



Bauer ("Dietary of the Sick") says: "The functional activity 
and resisting power of the organism seem to be essentially connected 
with the presence of an ample supply of albumin. 

" Animal food requires a considerable quantity of oxygen for its 
complete combustion, and a diet of this nature increases the demand 
for oxygen and favors its consumption. Meat in general has a more 
stimulating effect upon the system, and is more strengthening than 
vegetable food, and it gives rise to sensations of energy and activity. 
A meal consisting of meat remains an hour or two longer in the 
stomach than a purely vegetable meal. It seems to satisfy the crav- 
ings of hunger, bulk for bulk, to a greater extent and for a longer 
time than vegetable food, and a man can live longer upon exclusively 
nitrogenous food than upon exclusively carbonaceous food. Animal 
food occupies less space in the stomach, and is more portable than 
vegetable food. Moreover, albuminous foods can be eaten longer 
alone without exciting loathing, as a rule, than can fats, sugars, or even 
some pure starches. In fact, there is a constant tendency to eat 



Force Production — Energy from Food. 829 

too much meat, and when its effects are not counterbalanced by free 
outdoor exercise, it produces an excess of waste matter which accumu- 
lates and causes biliousness, and sometimes lithiasis, gout, etc." 

Fothergill wrote: "In an excess of nitrogenized food we find the 
cause of much of the lithiasis, or gout, whether regular, irregular, or 
suppressed, with which we are brought into contact." A carbonaceous 
diet taxes the excretory organs to a lesser degree than animal food. 

Sir H. Thompson says, "It is a vulgar error to regard it in any 
form as necessary to life." Nitrogenous food man must have, but it 
need not necessarily be in the form of meat, which "to many has 
become partially desirable only by the force of habit, and because 
their digestive organs have thus been trained to deal with it." 

This is no doubt true; "but training has become so strongly a 
matter of heredity through, many centuries that those who possess it 
are certainly in better health for a reasonable allowance of meat in 
their dietary." Errors in diet are far more common on the side of 
excessive meat-eating than the eating of too much vegetable food, 
especially among civilized communities. In the temperate an in- 
crease in prosperity, together with the improvements made in the 
methods of preparing and preserving meat, as well as those in breed- 
ing cattle for market purposes, tends to increase the habit of meat- 
eating. The estimate commonly given, in which meat should occupy 
one-fourth and vegetable food three-fourths of a mixed diet, is over- 
stepped by many persons with whom the proportion may be two to 
four. There is often too much eating of cold meats at luncheon for 
the interest of health. 

The proper association of different foods always keeps healthy 
men in better condition than too long continuance of any selected diet 
system. 

Sir. H. Thompson, in speaking of the advantages of a well- 
proportioned diet, says: "A preference for high flavors and stimulat- 
ing scents peculiar to the flesh of vertebrate animals, mostly subsides 
after a fair trial of milder foods when supplied in variety. 
The desire for food is keener, the satisfaction in gratifying appetite 
is greater and more enjoyable, on the part of the general light feeder, 
than with the almost exclusive flesh feeder. . . . Three-fourths, at 
least, of the nutrient matters consumed are from the animal kingdom. 
A reversal of the proportions indicated — that is, a fourth only from 
the latter source, with three-fourths of vegetable products — would 
furnish greater variety for the table, tend to maintain a cleaner pal- 
ate, increased zest for food, a lighter and more active brain, and a 
better state of health for most people not engaged in the most labori- 
ous employments of active life." 

Letheby wrote : "The best proportions for the common wants of the 
animal system are about nine of fat, twenty-two of flesh-forming sub- 
stances, and sixty-nine of starches and sugar. Whenever one kind of 



830 Force Production — Energy from Food. 

food is wanting in any particular constituent, we invariably associate 
it with another that contains an excess of it." 

Meats which are deficient in fat are usually eaten with added fat. 
Thus bacon is eaten with veal, liver, and chicken, and most fish are 
cooked with butter or oil. Similarly, butter, eggs, or cream are mixed 
with amylaceous foods, such as rice, sago, potatoes, etc., which are 
lacking in fat, and fat-containing cheese is added to macaroni. Bacon 
is added to beans, and pork to greens. A mixed diet is the only rational 
one for man, and it seems to be useless to reason otherwise. 

The combinations of foods which are by analysis shown to contain 
quantities of proteids, starch, and fat, have a very different effect in 
overtaxing the digestive organs according to the particular form in 
which the ingredients exist. 

It is a popular belief that meat requires more energy for diges- 
tion than starchy foods; but in health this is probably not time, pro- 
vided both varieties of food are taken in correct proportion; for it cer- 
tainly would be a strain upon the digestive system to be obliged to derive 
all the carbon needed from an exclusively meat diet, just as it overtaxes 
the alimentary canal to obtain sufficient nitrogenous material from an 
exclusively vegetable diet. The whole question devolves upon a true 
balance of ingredients of a mixed diet. (Thompson.) 

For man, certainly, nature never intended that all the nutrition of 
the body should be derived from any one class of foodstuff, which would 
require the use of certain digestive juices, and imply the disuse of 
others which are normally present. 

A diet of animal food is much less fattening than a vegetable 
regimen, or than carbohydrates with a fair proportion of fats; but 
a stout man will not necessarily endure fatigue, or even starvation, 
any better. On the other hand, to increase the proteid substances of the 
body, an albuminous diet, with but little carbohydrate, is necessary. 
, Men, unless greatly emaciated, have a reserve store of energy in their 
bodies sufficient to maintain their animal heat and keep them alive for 
from seven to nine days, and this is true whether they have been meat 
eaters or vegetarians. Storage of fat will help them out in emergencies ; 
but, if it has been overdone — i. e.,\i there is too much fat in the tissues 
— they may be weakened by it, and, although they have the material 
for force production on hand, they are unable to utilize it, and are worse 
off than if they were spare. 

Bauer says : "The material effects of albumin and fat in the system 
are in a certain sense opposed ; for the former increases the tissue waste, 
and secondarily the oxidation, while fat induces the opposite effects." 

VEGETARIANISM. 

It is said by Bauer and others that the universal experience has 
been that, though an almost exclusively vegetable diet may keep a man 
in apparent health for some time, it eventually results in a loss of 



Force Production — Energy from Food. 831 

strength and general resisting power against disease, which, becomes 
evident after some months, if not before. 

No doubt, much of the alleged benefit of vegetarianism is due to 
the greater freedom of the action of the bowels, induced by the use of 
bran bread and other coarse articles of food. 

It is a known fact that it is impossible to subsist for any length of 
time on a diet which does not contain a considerable quantity of nitro- 
gen, which constitutes so important an element in the composition of 
the great majority of structures of the body, and, in fact, of protoplasm 
itself. 

"Attempts have, from time to time, been made, for economic 
reasons, to furnish large bodies of laboring men, employed by contracts 
or otherwise, with a purely vegetable diet; but this diet is found to 
defeat its own ends, in that the maximum of labor can not be main- 
tained by men who are fed exclusively on vegetable food, although 
some carbohydrates are essential. It gradually induces a condition of 
muscular weakness and languor, with disinclination for either physical 
or mental work." 

Animal food in some form must be regarded as absolutely essentia), 
for all races of men. When the diet of enthusiastic vegetarians is care- 
fully analyzed, it is found that the strictly hydrocarbonaceous food is 
supplemented by such articles as milk, eggs, etc., which are used in 
cooking or in other ways, although the consumption of nitrogenous food 
may appear very much restricted. 

There are many facts in nature, in addition to those already dis- 
cussed, which indicate, without doubt, that man from his earliest pre- 
historic days has been omnivorous, adapting himself to his surround- 
ings, and eating, in his primitive condition, whatever his environments 
afforded with least expenditure of labor to obtain it, now vegetable, now 
animal food. This is shown in the structure of the teeth in prehistoric 
skulls, in the length of the alimentary canal, and in the character of the 
digestive organs and secretions as at present existing. 

The ancient Britons are known to have subsisted chiefly upon 
acorns, berries, roots, leaves, etc. ;' but other primitive tribes ate fish, 
shell-fish, and game when they could kill it. 

WATER. 

It is estimated that water composes about seventy per cent of the 
entire body weight, and it is an almost universal solvent. Its impor- 
tance to the system, therefore, can not be overrated. The elasticity or 
pliability of muscles, cartilages, and tendons, and even of bones, is 
in great part due to the water which these tissues contain. As Solis- 
Cohen says: "The cells of the body are aquatic in their habit. The 
amount of water required by a healthy man in twenty-four hours is, 
on the average, between fifty and sixty ounces, besides about twenty-five 
ounces taken in as an ingredient of solid food, thus making a total of 
seventy-five to eighty-five ounces. The elimination of this water is 



832 Force Production — Energy from Food. 

divided as follows : twenty-eight per cent through the skin ; twenty per 
cent through the lungs ; fifty per cent through the urine ; two per cent 
through other secretions and the fasces." This is, of course, a very 
general computation, for there are constant variations in the activity of 
different organs. 

A large proportion of the water is taken in the form of beverages 
composed chiefly of it, and by many persons they are substituted for 
plain water altogether. One of the most universal dietetic failings is 
neglect to take enough water into the system. 

USES OF WATER IN THE BODY. 

^ "The uses of water in the body may be summarized as follows : — 

"1. It enters into the chemical composition of the tissues. 

"2. It forms the chief ingredient of all the fluids of the body, 
and maintains their proper degree of dilution. 

"3. By moistening various surfaces of the body, such as the 
mucous and serous membranes, it prevents friction, and the uncom- 
fortable symptoms which might result from their drying. 

"4. It furnishes in the blood and lymph a fluid medium, by which 
food may be taken to remote parts of the body and the waste matter 
removed, thus promoting rapid tissue changes. 

"5. It serves as a distributor of body heat. 

"6. It regulates the body temperature by the physical processes 
of absorption and evaporation. 

"All protoplastic activity in cells ceases at once if they become 
dry. Elementary cells, such as the amoeba, cease to move, to digest, or 
to show any form of irritability as functional activity, when dry; but 
if water be added to them, their functions will be resumed, showing that 
they have been suspended and not necessarily destroyed." (Thomp- 
son.) 

The taking of much water into the stomach, by its mechanical 
pressure, excites peristalsis. One or two tumblerfuls of cold water 
taken into an empty stomach in the morning on rising favors evacuation 
of the bowels in this way. The water, moreover, is quickly absorbed, 
and temporarily increases the fulness of the blood-vessels. This pro- 
motes intestinal secretion and peristalsis. "The increased activity of 
the lower bowel is explained in this way rather than by the idea that 
the water itself reaches the colon and washes out its contents." 

Lukewarm water acts as an emetic if drunk in large quantity. 
This action fails above 95° Fahrenheit and below 60° Fahrenheit, and 
is most efficient at about 90° Fahrenheit. 

Water may be of service to eliminate waste in various renal dis- 
eases, gout, lithiasis, oxaluria, renal inadequacy, fevers, and infectious 
diseases. If drunk too freely with meals, it lessens the activity of 
saliva. Water drunk towards the conclusion of the gastric digestion of 
a meal (i. e., two or three hours after taking food) serves to dilute the 
contents of the stomach, and wash them more readily into the intestines. 



Force Production — Energy from Food. 833 

If stomach digestion has been slow and feeble, so that the whole process 
has been greatly prolonged, the drinking of six or eight ounces of water, 
either hot or cold, two hours or more after taking food, will facilitate 
its digestion. Water is highly useful in constipation, and it is more 
quickly absorbed from the stomach when the tension in the gastric ves- 
sels is low. It is imperatively needed after severe hemorrhage, or 
after the sudden loss of blood from the system from any cause, such 
as the evacuations of cholera morbus, Asiatic cholera, etc. 

Water is to be restricted in dilatation of the stomach, the secre- 
tion of weak gastric juice, and sometimes, but not always, in diabetes 
insipidus, diabetes mellitis, ascites, and other dropsies, ansarca, and 
in some forms of heart disease and obesity. The daily quantity of 
water ordinarily drunk varies between two and a half and four pints. 
About one and a half pints more are taken in the food, and four or five 
and a half pints are therefore lost through the emunctories. 

The foods which contain most water are milk, and succulent fruits, 
such as grapes, oranges, grapefruit, lemons, watermelons, etc., and 
vegetables like the tomato, squash, and many others of tropical origin. 

EXCESS OF WATER. 

If very large quantities of water, or any fluids consisting chiefly 
of water, are imbibed through a long period, they tend to overwork the 
kidneys and produce various alterations in the tissues. Practically^ 
however, it seldom happens, excepting in some forms of gastric or intes- 
tinal disorders, and other instances mentioned above, that too much 
water is taken. When drunk in such fluids as beer or diluted liquors, 
the resulting disturbances of the system are attributable rather to other 
ingredients. 

Laymen are usually more willing to ascribe obesity to supposed 
excessive consumption of fluids than to overeating. They often say 
that they supposed water was "fattening." It is so only in the sense 
that it promotes tissue change or metabolism, and washes away waste 
matter, not in the sense that it is itself a storage substance, as fat is. 

WATER STARVATION. 

When water is withheld from the system for a considerable length 
of time its absence is first apparent in the secretions and excretions, and 
next in the various tissues of the body, the last of all being those of the 
nervous system. More than ten or twelve hours of abstention from 
drinking produces uncomfortable thirst, and one or two hours of violent 
exercise may do so at once. 

THIRST. 

As far as the individual is concerned, the suffering from depriva- 
tion of water is mainly confined to the sensations of thirst and dryness 
of the mouth. Thirst is commonly, and somewhat erroneously, referred 
to the mouth and pharynx. It is true that the mucous membrane in 
these regions becomes dry when water is withheld, but thirst may also 

53 



834 Force Production — Energy from Food. 

be keen when these surfaces are abundantly moist. The sensation is 
the result chiefly of the expression through the nervous system of the 
need of the body tissues in general for fluid, and it is referred to the 
mouth and throat from force of habit, which associates the act of swal- 
lowing fluid, and the use of certain muscles in that process, with the 
subsequent relief of thirst. "It is asserted that shipwrecked sailors 
in open boats have relieved their thirst by immersing their bodies in 
salt water. Ordinarily, the skin is not capable of absorbing fluid of any 
kind to a practical extent, but immersion in water prevents evaporation 
from the surface of the body, and by saving its loss in that direction 
lessens thirst. Sucking a slice of lemon or drinking water acidulated 
with a few drops of lemon- juice or vinegar, sometimes allays thirst 
better than plain water. Lemon- juice and ice is another remedy. 
Bitartrate of potassium or very weak brandy may be used for the same 
purpose, and is sometimes more satisfying. Hot water, as hot as it 
can be sipped, quenches thirst much better than cold, which is of little 
avail." (Balfour.) 

SALTS. 

The principal salts derived from the food are as follows : — 
Chloride of sodium and potassium; carbonates of sodium, potas- 
sium, and magnesium ; sulphate of sodium and magnesium ; phosphate 
of sodium, potassium, magnesium, and calcium. The majority of these 
salts are held to be unaltered by digestive processes, and pass into the 
blood or tissues without necessary chemical change. 

USES OF SALTS IN" THE FOOD. 

The uses of the salts derived from the food are summarized as fol- 
lows : — 

1. To regulate the specific gravity of the blood and other fluids of 
the body. 

2. To regulate the chemical reaction of the blood and the various 
secretions and excretions. 

3. To preserve the tissues from disorganization and putrefaction. 

4. To control the rate of absorption by osmosis. 

5. To enter into the permanent composition of certain structures, 
especially the bones and teeth. 

6. To enable the blood to hold certain materials in solution. 

7. To serve special purposes, such, for example, as the influence 
of sodium chloride on hydrochloric-acid formation, and that of lime 
salts in favoring coagulation of the blood. (Chambers.) 

EXCESS OF SALT. 

Salts of any kind, when taken in excess with food, disagree with 
digestion in various ways. They may prove a local irritant to the 
gastric or intestinal mucous membrane. They modify the rate of ab- 
sorption of digestive material, and alter the intensity of reaction of the; 
different digestive fluids. 



Force Production — Energy from Food. 835 

DEPRIVATION OF SALT. 

Continued deprivation of any one of the common salts, so long as 
others are furnished in reasonable abundance in the food, does not 
result seriously. If, however, all the salts are reduced in quantity, or 
if they are entirely excluded from the diet, the system very soon begins 
to evince signs of malnutrition. Animals or men deprived of salts 
for a long time suffer greatly from indigestion and from lack of bodilv 
nutrition. The body may not diminish in weight, but the tissues be- 
come flabby, the muscles feeble, the mind stupid and dull; the nutri- 
tion of the skin is altered ; it becomes dry, and the hair falls out. Even- 
tually in animals with salt starvation death occurs in from six to eight 
weeks from progressive bodily weakness and inanition, — a condition, 
practically, of marasmus. 

Young infants who do not obtain sufficient salts of lime, i. e.,\l fed 
upon proprietary infant foods instead of good milk, become rachitic ; 
their bones ossify slowly, and bend into deformities. Such children 
should be properly fed on milk. 

SODIUM CHLORIDE. 

Table salt is by far the most important and valuable salt, and is 
used in the largest amount. Common salt stimulates the appetite and 
influences beneficially the gastric secretion. It not only furnishes the 
chlorine for hydrochloric acid, but seems to act locally in the stomach 
by promoting this secretion, as well as the conversion of pepsinogen into 
active pepsin. It has been proven that the absence of salt from the 
diet completely checks the production of hydrochloric acid in the 
stomach. (Cohn.) 

POTASSIUM SALT. 

Next in importance to sodium chloride (table salt) is potassium 
salt, which is the predominant salt of the muscles, and which, like 
sodium chloride, is a common ingredient of nearly all the tissues and 
fluids. The acid and neutral carbonates and phosphates of sodium and 
potassium are chiefly important in regulating the reaction of the 
digestive secretions and the urine. 

CALCIUM. 

These are chiefly of value from their constituting a large percent- 
age of the composition of the bones and teeth, as well as a smaller per- 
centage of many other tissues of the body. 

PHOSPHORUS. 

Phosphorus is derived from phosphates in meat and its contained 
blood which is eaten, as well as from vegetables. It enters into the 
composition of the bones, muscles, blood, etc. 



836 Force Production — Energy from Food. 

SULPHUR. 

Sulphur is derived from sulphates contained principally in fibrin,, 
egg albumen, the casein of milk, and from such vegetables as corn, 
turnips, cauliflower, and asparagus. 

IKON". 

The iron is found in the blood pigment, where it amounts, all told, 
to a third of an ounce. It is also present in minute traces in other 
pigments. Its chief source is from the blood of animals which is 
cooked with their meat, It is also derived from, and it may be taken 
with, chalybeate waters. 

VEGETABLE ACIDS. 

The common organic or vegetable acids — citric, tartaric, malic, 
etc. — are derived from fresh vegetables and fruits, in which they exist. 

ANIMAL FOODS. 

Animal foods contain much nutrient matter in a more or less con- 
centrated form, which exists in practically the same chemical combina- 
tion with the body itself. They leave comparatively little residue, 
being thoroughly digested. 

MILK. 

The milk of several animals, such as cows, goats, asses, mares, and 
camels, may be used for food, but in this country little other than cow's 
milk is employed. Milk contains the elements which are necessary for 
the maintenance of life in fairly economical proportion, so that for 
infants it constitutes a "complete" food, which fully meets the require- 
ments of the growing body, and in adults it will sustain life comfortably 
for many months. 

For these reasons milk ranks among the most important of all 
foods, and it is necessary to determine to what extent it should be 
introduced into ordinary diet. A pint of milk may be said to repre- 
sent approximately the nutrition contained in six ounces of beef or 
mutton. Although it furnishes so useful a food, milk is by no means 
essential to a diet designed for increasing bodily strength, and it is 
usually omitted from the menu of athletes in active training. Adults 
who are able to eat any kind of food usually maintain their health 
in better condition by abstaining from milk except as used for cook- 
ing purposes, inasmuch as it makes many persons bilious to drink it, 
and produces constipation, particularly when taken in excess with other 
foods. 

AN EXCLUSIVE MILK DIET. 

An exclusive milk diet is usually desirable in the following condi- 
tions and diseases : — 

1. In infancy for the first year, and sometimes for the first eighteen 
months. 



Force Production — Energy from Food. 837 

2. In all acute diseases of young children. 

3. In typhoid fever. 

4. In acute Bright's disease, and sometimes chronic nephritis. 

5. In acute pyelitis. 

6. In chronic gastric catarrh. 9 

7. In gastric ulcer and carcinoma. 

8. In neurasthenia. 

A milk diet is easy to prescribe, so cheap and so easily procured, 
that it is always the first resort of those who from indifference or lack 
of knowledge of the first principles of dietetics, are unwilling or unabk; 
to take pains to study the peculiarity and needs of the individual case. 

An exclusive milk diet in time becomes monotonous and weari- 
some to most adults, and may produce dyspepsia and constipation, and 
interfere with the functional activity of the liver. Aside from nausea, 
which the continued use of milk may excite, a positive loathing for th^ 
taste of it is apt to be developed, unless the regimen is modified by 
occasional variations. This is a matter of considerable importance in 
feeding patients suffering from typhoid fever, chronic Bright's dis- 
ease, chronic gastric catarrh, and other affections for which milk diet 
is often prescribed; for if other substances are substituted from time 
to time in small amounts, while milk is still retained as the chief food, 
it may be continued as such for a much longer time. On seeking the 
cause for the disagreement of milk, it is found in the fact that it con- 
tains too large a proportion of nitrogenous material as compared with 
the hydrocarbons, so that, in order to obtain sufficient of the latter, an 
excess of proteid is ingested, which interferes with digestion. 

MILK CUKE. 

The milk cure has been carried out successfully by Pecholier, 
Weir Mitchel, Karell, and others for the treatment of obstinate hys- 
teria, hepatic congestion, dropsy, and various anomalies of nutrition. 
The patient is given no food but milk, which Pecholier orders every 
two hours in small amounts, increasing the quantity until three litres a 
day are taken. Mitchel commences with doses of half an ounce to two 
ounces every two or three hours, and increases the dosage by half an 
ounce until six ounces or more are taken. If thirst is complained of, 
natural water or Seltzer water is given. If the taste of the milk is 
complained of or is disagreeable, coffee, salt, or caramel is added. Alter 
three or four weeks, rice, arrowroot, and thin slices of white bread are 
allowed, and after five weeks raw meat or one or two cutlets (the loin 
cutlets are the best). The milk, meanwhile, is continued. After a 
day or two of this treatment, hunger and thirst are not usually com- 
plained of. At first the pulse is accelerated, but there is seldom any 
conspicuous nervousness. The tongue is coated ; the water in the urine 
is increased; there is obstinate constipation (which must be relieved 
by enemata or medicines) ; the stools are hard, and ochre or white in 
color, and a great deal of epigastric distress and a feeling of emptiness 



838 Force Production — Energy from Food. 

are present. The arterial tension is lowered; there may be muscular 
prostration ; there is loss of weight at first. If the treatment is perse- 
vered in, at the end of a fortnight there is marked improvement in the 
feeling and condition of the patient, and after six or eight weeks the 
cure is usually far advanced. 

RAW EGGS. 

Whole raw eggs are very popular in dietetics at present, and they 
are often prescribed when a nutritious, highly-concentrated diet is de- 
sired, as in the case of consumption and some forms of anaemia, and 
various wasting diseases. Sometimes from a half dozen to a dozen a 
day are given, if they can be digested. 

They are given in the form of egg-nog, or beaten up with milk, 
also with coffee ; or they may be given in port wine or sweetened water. 
In fever cases egg-nog can not be taken. The whites of eggs (egg 
albumen) only should be used where egg-nog does not agree with the 
patient. A raw egg is ordinarily digested in the stomach in one and 
a half hours, but an egg baked in a pudding requires from three and 
a half to four hours to digest. 

An excellent way to cook an egg is to have a quart of boiling water ; 
lift the vessel from the stove, drop the egg into the boiling water, set it 
aside on a table, and let it stand five or six minutes. Then break the 
egg into a warm tumbler, add a pinch of salt and pepper if desired, also 
a very little fresh butter may be allowed. In the ordinary rapid cook- 
ing of eggs in boiling water the white is firmly set before there is time 
for the temperature of the interior of the egg to be thoroughly raised, 
and consequently the yolk is softer than the white. 

In cooking omelets and scrambled eggs, the white is thoroughly 
mixed with the yolk, and the egg is more digestible than when fried or 
cooked so much that the albumen is hard. 

TO PRESERVE EGGS. 

Eggs decompose from the admission of germs through their porous 
shells. They may be coated with varnish, tinfoil, butter, or any fat 
or oil not liable to become rancid. Packing in sawdust also excludes 
the air to a slight extent. 

MEATS. 

A meat diet, if long continued, tends to produce scurvy, and the 
absence of meat favors the occurrence of anaemia in many persons. In 
general, those diseases in which an exclusive meat diet, or a diet com- 
posed almost exclusively of animal food, with perhaps a minimum of 
dry bread, is found beneficial, are the following: Flatulent dyspepsia, 
chronic gastritis and gastric catarrh, and dilatation, diabetes, intestinal 
dyspepsia, phosphaturia, obesity, and some cases of chronic dysentery. 
Meat should also enter largely into the diet of consumptives and anaemic 
subjects. 



Force Production — Energy from Food. 839 

It is well to reduce or prohibit the consumption of meat in acute 
and chronic Bright's disease, gout, and rheumatism, lithsemia, and 
oxaluria. 

Raw meat is a prevalent fashion at present, being prescribed in 
some diseases, such as dysentery or chronic gastritis. It is useful, but 
it should not be given with the idea that it possesses any special curative 
value from the fact of being raw. Beef, mutton, and ham are all eaten 
in this condition. Raw meat has no advantage, either in digestibility 
or nutrient power, over moderately cooked or "undone" meat, (Thomp- 
son.) 

TABLE OF COMPARATIVE DIGESTIBILITY OF MEATS. THE MOST 

DIGESTIBLE IS GIVEN FIRST, ENDING WITH THE 

LEAST DIGESTIBLE. 

Oysters. 

Soft-cooked eggs. 

Sweetbread. 

White fish, boiled or broiled. 

Chicken, boiled or broiled. 

Lean roast beef or beefsteak. 

Eggs, scrambled or omelet. 

Mutton, roasted or boiled. 

Squab, partridge. 

Bacon. 

Roast fowl, chicken, capon, turkey. 

Tripe, brains, liver. 

Roast lamb. 

Chops, mutton or lamb. 

Corned beef. 

Veal. 

Ham. 

Duck, snipe, venison, rabbit. 

Salmon, mackerel, herring. 

Roast goose. 

Lobsters and crabs. 

Pork. 

Smoked, dried, or pickled fish, and meats in general. 

Bauer places the order of easiest digestibility of meats in delicate 
stomachs as follows: Young poultry (fowl or pigeons), veal, game, and 
beef. 

BEEF PREPARATIONS FOR THE SICK. 

Beef is so important a food for well and sick alike that many 
attempts have been made to improve its digestibility for the latter. 

Much attention has of late been given to the predigestion of meat, 
and especially of the production of albumoses, which are more soluble 
and assimilable than undigested meat albumin, and which are said to 
possess greater nutritive property than peptones. In general, about 



840 Force Production — Energy from Food. 

three grams of meat extract constitute a good soup ration, and such 
preparations are often valuable for addition to invalid soups and broths 
when thickened with egg, rice, sago, pearl barley, macaroni, ground 
toast, etc. 

The preparations of meat for the sick are both solid and fluid. 

SOLID MEAT PREPARATIONS. 

Scraped meat is best made from tender beefsteak broiled for a 
few minutes over a brisk fire; but rare roast beef or mutton chops may 
be used. The pulp is best scraped out with a dull knife or iron spoon. 
The indigestible and less nutritious connective-tissue sheaths of the 
muscle fasciculi are broken and left behind, while the fibers themselves 
are obtained in the form of a soft, unirritating mass, which is readily 
acted upon by the gastric juice. The pulp may be run through a 
sieve. It is then salted, and it may be made into little balls and 
browned just before eating. This is done by placing the balls on a 
hot frying-pan, which is not greasy, and turning them over so that the 
outside becomes well seared. They should then be set aside on a cooler 
part of the stove and allowed to remain a few minutes until the raw- 
red color of the interior turns slightly to a drab. 

Some patients prefer to eat the meat scarcely cooked, spread as a 
sandwich between thin slices of bread and butter. This meat (with- 
out the bread) may be fed to infants in their second year, and the mea* 
balls are invaluable in the treatment of chronic gastritis, dilatation of 
the stomach, typhoid convalescence, and other affections. 

mosquera's beef meal. 

This is made by digesting fresh, tender, lean beef, with pine- 
apple juice until the muscle fiber is almost completely converted into 
peptones. After digestion, the preparation is desiccated. 

Chittenden's analysis of this meal shows it to contain ninety per 
cent of nutriment, thirteen per cent of which is fat and seventy-seven 
per cent is proteid. 

The beef meal is tasteless and odorless, which are decided advan- 
tages, as it can be flavored according to preference. It should be salted, 
and may be added to broths and soups. D. D. Steward advises its 
use with equal parts of sugar and cocoa. This mixture is added to 
hot milk. 

darby's fluid meat. 

This is a moist extract which has a strong meaty taste. It can be 
eaten spread on thin bread and butter or cracker, or it may be dis- 
solved in hot water. 

Powdered beef, beef-blood dried, meat lozenges, beef peptonoids, 
beef extracts, beef tea, and beef juice are all useful preparations, and 
the family physician prescribes such preparations as are suited to each 
individual case. 



Force Production — Energy from Fooa. 841 

FISH. 

Fish, vary both in digestibility and nutritive qualities. The chief 
differences are in regard to coarseness of fiber and the quantity of fat 
present. Fish meat is less stimulating, sustaining, and satisfying than 
that of birds or mammals. The following fish, in the order named by 
Walker, have the largest percentage of albuminoids: Red snapper, 
white fish, brook trout, salmon, blue fish, shad, eels, mackerel, halibut, 
haddock, lake trout, striped bass, cod, flounder. 

All fish are best in their proper season, for out of season they 
deteriorate from change in food or other causes, and are less nutritious, 
besides possessing inferior flavor, and sometimes disagreeable odor. 

They should be eaten as fresh as possible, for there are few ali- 
mentary substances capable of exciting so violent gastro-intestinal dis- 
turbance as decomposing fish. 

There are no diseases in which a fish diet is said to possess specific 
value, but often in chronic Bright's disease, lithsemia, gout, or other 
conditions in which it is undesirable to give much meat, it is very 
serviceable as a change. 

SHELL-FISH. 

Oysters, clams, and mussels are nutritious food, and the former 
are more often prescribed. Eaten raw or properly cooked, they are 
excellent invalid aliment. Oysters can often be digested earlier than 
meat in convalescence from fevers, etc. 

SUGAFS. 

Sugars are crystallizable carbohydrates, in which oxygen and 
hydrogen exist in proportion to form water. There are many varieties, 
of which the commoner contained in food or used as an adjunct to diet 
are cane sugar, saccharose, grape-sugar or glucose, and sugar of milk 
or lactose. Inosite, mannite, dextrine, sugar of malt or maltose, honey, 
a sweet nitrogenous substance called charin, and fruit sugar or levulose, 
are also used. Sugar may be derived from stems of plants, as in case 
of sugar-cane, or the palm, from tubers like beet, from maple-tree sap, 
and from other vegetable growths. 

As foods, sugars have essentially the same uses as starches, for all 
starches must be converted into dextrine or sugar before they can be 
assimilated. For this very reason, sugars, although they form an excel- 
lent class of foods, producing force and heat and fattening the body, 
are not absolutely necessary for the maintenance of health if starches 
or fats are eaten. Many persons acquire an inordinate fondness for 
sugar, and overindulgence in this food is very sure to give rise to 
flatulent dyspepsia, constipation, and disorders of assimilation and 
nutrition. It may cause functional glycosuria. Sugar is very fatten- 
ing. Sugars are emphatically force producers. Chauveau and Kauf- 
mann have demonstrated that during muscular activity the consump- 
tion of sugar in the body is increased fourfold. 



£42 Force Production — Energy from Food. 

CEREALS AND OTHER STARCHY FOODS ; STARCHY FOODS IN GENERAL. 

The cereals in commonest use as food products are wheat, corn, 
rice, rye, barley, oats, buckwheat. From these are manufactured a 
variety of flours and meals. Besides the cereals are vegetables, which, 
like the potato, are composed chiefly of starch. There is a large mis- 
cellaneous group of starchy foods used as flours, which are therefore 
conveniently considered with cereals. Such are arrowroot, tapioca, 
cassava, sago, and peas. Peanuts, chestnuts, and plantains are also 
sometimes used to furnish flour. 

Farinaceous foods are composed of flour of different kinds, and 
constitute a subdivision of starchy foods. The different starchy and 
farinaceous foods are derived from a variety of plant structures, includ- 
ing roots, tubers, bulbs, stems, pith, flowers, seeds, fleshy fruits, etc. 
Some, like the banana and certain vegetables, are eaten raw, but the 
majority require cooking, and the starches derived from grain-bearing 
plants of the grass tribe or cerelia usually must be prepared by grind- 
ing and milling before cooking. 

COMPOSITION OF BREAD. 

Bread is really a mixed food, in that it contains so many classes 
of ingredients, — fat, proteid, salts, sugar, and starch ; and this is prob- 
ably the explanation of the fact that its daily use never cloys the appe- 
tite. Although it contains some fat, it has not enough for a perfect 
food, and hence the almost universal custom of using butter with it. 
Moreover, it forms a convenient vehicle for taking fat in this manner, 
and the butter aids in the mastication and deglutition of the bread. 

VARIETIES OF BREADSTUFFS. 

Bread of different kinds constitutes the staple starchy food for 
Americans, as the potato does for the Irish peasantry, and macaroni 
does for the Italians. 

The most important bread used, both from the standpoint of itb 
nutritive value and the quantity consumed, is derived solely from wheat 
flour; but, for economical or other reasons, this flour is sometimes ad- 
vantageously mixed with potatoes or bean flour. The latter, added in 
the proportion of one part to ten of wheat, is said to give a white bread 
rich in nitrogen and highly nutritious. Corn flour may be mixed in 
the same proportion. 

Whole-meal Bread. — For some flours the whole of the wheat is 
used, the gluten, nitrates, and phosphates being all retained. They are 
more delicate than oatmeal, and more digestible. Wheat yields soluble 
matter, such as albumin and dextrine, amounting together to about ten 
per cent, besides various salts. The insoluble matter of the grain is 
chiefly starch and gluten, which constitute from seventy to seventy-five 
per cent. Wheaten bread contains about twenty-five per cent of car- 
bon and one to two per cent of nitrogen (or about eight per cent of 
proteid material). 



Force Production — Energy from Food. 843 

Pumpernickel. — This is a German black bread, made of unbolted 
meal and sour dough. It is somewhat laxative. 

Zwieback. — This is a thoroughly dry form of bread, which is very 
wholesome for invalids. It contains about sixteen per cent of solids. 

Graham Bread. — This bread is so called after Sylvester Graham, 
who advocated its use. It differs from white wheat bread by contain- 
ing the outer coatings of the wheat kernel, called bran, which contains 
a larger per cent of albuminous material and phosphates. The bran, 
however, while containing serviceable food products, is so difficult of 
digestion that it tends to irritate the mucous membrane of the intes- 
tines, and increase peristaltic action. For this reason it is more lax- 
ative than white wheat bread, but also less nutritious. 

Gluten Bread.- — Bread made from gluten flour is useful where 
there is a tendency to obesity, and is given to diabetics. It may be 
toasted like ordinary bread. 

Rye Bread. — Next to wheat, rye is the most important bread- 
making flour, although it is less digestible for invalids, and it may be 
mixed with wheat flour in the proportion of two parts of the former to 
one of the latter. 

PREPARED FARINACEOUS FOODS. 

(Often called irifant food.) 

Prepared farinaceous foods are made, first, by the application 
of heat alone ; second, by digestion with malt or diastase combined with 
heat; third, after dextrinization, the food is evaporated with milk or 
cream. 

The prepared farinaceous foods may be eaten alone or diluted with 
water, but they are usually given to invalids in a cup of broth or beef 
tea, which disguises their sweetness. The sweeter varieties are best 
combined with milk. 

Imperial granum is a type of a large class of prepared foods, the 
basis of which is starch, which has been modified, it is claimed, so as 
to render it easily digestible. Such foods are often fed to very young 
infants, which has proven to be the greatest mistake that can be made ; 
for their digestive apparatus is wholly unfit to deal with starch in any 
form. The human infant is designed to be nursed at the breast for 
the first year of life, and nature has furnished ample food for it which 
is wholly devoid of starch. The saliva and pancreatic secretions, upon 
which the digestion of starches depends, are not fitted for this work at 
all during the first eight or nine months of life, and then only partially ; 
nence starchy foods — "farinaceous baby foods" — should never be given 
at all before that age as foods, and should only be used very sparingly, 
if at all, as mechanical diluents of milk. (Starr.) 

Granum is composed of over three-fourths starch, made into a fine 
flour. One teaspoonful of it should go to each three ounces of water, 
in which it is boiled for ten minutes. An equal quantity of milk is 
then to be added, and the mixture must again be boiled for five minutes. 



844 Force Production — Energy from Food. 

The mixture may sometimes be fed to an infant after the eighth month 
of age, but only once or twice in twenty-four hours. 

Flour Boll. — This is prepared by boiling wheat flour tied in a 
bag, for the purpose of converting it into dextrine, and it is a popular 
belief that this conversion is almost if not quite complete. But Leeds 
has shown by recent analysis that even after seventy-five hours of con- 
tinuous boiling the percentage of soluble carbohydrates is increased by 
only .05 of one per cent; whereas some of the prepared foods contain 
from two to six times as much soluble carbohydrates as wheat flour. 

Mellin's Food. — This food consists of sweetish granules, easily 
soluble in both hot and cold water, milk, etc. It is made of coarsely- 
ground wheaten flour, with the addition of malt and potash. It is then 
digested with water at a moderate temperature to form dextrine and 
sugar. Afterwards it is strained through sieves, and evaporated in a 
vacuum pan. 

Mellin's Food is often fed to infants, but it contains too much 
sugar without fat for a wholesome baby's food for continued use in 
quantity. About one teaspoonful is dissolved in two ounces of water 
and half a pint of milk. It may be resorted to temporarily when good 
cow's milk can not be obtained. 

Malted Milk.— This is a powdered sterilized preparation of pure 
cow's milk and extract of barley and wheat, the starch of which has 
been converted into dextrine. The mixture is dried in vacuo. The 
directions for its use are given on the labels on each bottle or jar. 

Bread Jelly. — A bread jelly may be made, to add to milk for in- 
valids, and for use while weaning infants who are old enough to digest 
a little starch, i. e., over one year of age. Crumbs of stale bread are 
broken into small fragments, covered with boiling water, and allowed 
to soak until well macerated. The water is strained off, fresh water 
is added, and the mass is boiled until quite soft. On cooling, a jelly 
forms which may be mixed with milk in any desired proportion. 

F arena. — This is a general name meaning flour, and is defined bj 
Webster as "the flour of any species of corn or starchy root." Much of 
the gluten and bran has been separated, rendering it less nutritious than 
whole wheat. In case of diarrhea it is more bland and less irritating 
than whole wheat. The name farina is also applied to fine, white 
potato starch, which forms a jelly when cooked, like arrowroot. 

Wheatena.- — This is a nutritious food, containing all the wheat 
berry excepting the husk, and thereby differing from finer preparations 
in which the layer gluten cells are removed with the bran. It is com- 
monly eaten as a thin mush or porridge. 

Crackers. — All kinds of crackers enter more into the dietary in 
America and England than in any other country. The lighter forms 
of sugar wafers are nutritious and very easily digested by invalids hav- 
ing mild gastric disorders, for the starch has been well torrefied. 

Corn, maize, or Indian corn, is very extensively grown in tern- 



Force Production — Energy from Food. 845 

perate and warm climates all over the world. It may be dried, parched, 
roasted whole, or ground into meal of various degrees of fineness. 

Corn is a wholesome cereal, for it contains considerable fat and 
proteid as well as starch, and it furnishes abundant energy, producing 
heat. It is very fattening for both the lower animals and man. 

Com-meal. — Corn-meal is quite digestible, and, like oatmeal, is 
somewhat laxative. As compared with wheat en flour, it contains more 
fat, having about nine per cent; but it is deficient in salts. It makes 
a dry, friable bread. 

Bice. — Although less eaten in this country than wheat, corn, and 
rye, except in the southern states, rice constitutes the staple food of a 
majority of the world's inhabitants. Asia produces most of the rice 
consumed. Both the Chinese and Japanese make a wine from rice, and 
a vinegar can also be obtained. 

Rice contains more starch than any other cereal, — from seventy- 
five to eighty-five per cent, — and is an exceedingly digestible form of 
starch for invalids when properly cooked, so that the individual grains 
are swollen or softened. This process is best attained by steaming. 
The digestibility of plain boiled rice is improved by eating it with a 
little fresh butter. Rice pudding, milk and rice, and rice with beef- 
steak juice constitute excellent foods for young growing children, and 
for use in convalescence from typhoid fever, diarrheas, and many other 
diseases. It is also advantageous to eat rice with prunes or apples. 

Barley.- — Barley ranks very close to wheat in nutritive qualities, 
and cooked barley-meal, like wheaten flour, contains gum, albuminoids, 
starch, and dextrine. As compared with wheat, barley contains more 
fat, salts, and indigestible cellulose, less proteid, and less digestible 
carbohydrates. 

Barley-water makes an excellent diluent and demulcent drink for 
infants and invalids. For invalids it may be flavored with lemon-juice. 
It may be made as follows : Grind half an ounce of pearl barley in a 
coffee mill, add six ounces of water, boil twenty minutes, add salt, and 
strain. It should be made fresh daily, and kept in a cool place. 

Oatmeal. — Oats contain considerable fat, proteid, salts, and indi- 
gestible cellulose, in addition to a large percentage of starch. For those 
who can digest oatmeal well, it ranks among the cheapest and most 
satisfying of foods. 

The nutritive value of oatmeal is great, but it depends very largely 
upon the skill with which it is cooked. For most persons, and espe- 
cially for all those with limited digestive power, oatmeal should be so 
thoroughly cooked as to acquire the consistence which enables it. to be 
easily poured, and on cooling it should form a tender gelatinous mass 
Oatmeal is a very hearty food, and those who eat much of it should 
live a vigorous outdoor life. If ill-cooked, and given to very young 
children, it occasions colic, flatulence, and rash. 

Arrowroot. — Arrowroot is derived from the rhizomata or root- 
stocks of several kinds of tropical plants grown in both the East and 



846 Force Production — Energy from Food. 

the West Indies. The roots are washed, reduced to a pulp, strained, 
dried, and pulverized into a very tine, starchy flour. It has a very 
bland, insipid taste, and when cooked it is as digestible as any starch 
used in making gruel or jellies for invalids, if not even more so. In 
bad cases of dyspepsia, when much gastric irritation exists, it often con- 
stitutes a serviceable article of diet. Arrowroot is sometimes fed to 
young infants, but it is unwholesome for them, and sours on the 
stomach. 

Tapioca, Cassava. — Tapioca and cassava are made from the rhizo- 
mata of the Manioc utilissima (spelled also manihot), a common plant 
in temperate and tropical regions. Tapioca, which is purified cassava, 
i$ made, like sago, by drying on hot plates. It is an almost pure 
starch. Tapioca may be eaten alone in the form of puddings, with 
cream, or flavored with lemon juice, mace, wine, or other spices. 
Pearl tapioca is a spurious article made from potato starch. 

Sago. — Sago is an easily-digestible form of starch derived from the 
pith found in the stem of different varieties of palm in Sumatra, Java, 
and Borneo. It is commonly sold in market in a granular form, and 
is known as pearl sago. Sago is made, with milk, cream, and eggs, 
into nutritious puddings, and it may be used to thicken broths and soups 
of various kinds. 

STARCHY FOODS FOR CHILDREN. 

The best cereals and other starches for children are rice, hominy, 
Indian meal, barley, oatmeal, cracked wheat or wheaten grits, farina, 
corn-starch, and sago. When the cereal grains are used instead of flour, 
they should be soaked in cold water for five or six hours, and then 
cooked for two or three hours in a double boiler. If fed to infants 
less than two years of age or to children with any gastro-mtestinal 
disorder, they must be thoroughly strained. They should be salted and 
served with cream, but without sugar. Bread and crackers may be 
allowed to infants after the first eighteen months, but only with their 
meals. 

VEGETABLE FOODS. 

Nearly all great divisions of the vegetable kingdom afford whole- 
some food for man. 

Vegetable food eaten in large quantity increases the elimination of 
carbon dioxide from the lungs. It also makes the urine alkaline, and 
intensifies the alkalinity of other secretions. 

The chief vegetable proteids are vegetable albumin, vegetable 
casein or legumin, and gluten. These proteids are less rich in nitro- 
gen than corresponding animal albumen. 

A purely vegetable diet is not economical for a laboring man, for 
the reason that to derive sufficient nitrogenous substance from it he 
must either obtain the very best and most expensive cereals or legumes, 
or he must eat a very large quantity of vegetables. By the addition 
of albuminous food or fat to his diet, he saves both expense and wear 



Force Production — Energy from Food. 847 

and tear of his digestive organs. If unable to obtain fresh meat, he 
may employ for this purpose milk, bacon, lard, and dried fish, snch as 
herring or cod. Among vegetable foods, oatmeal and beans will fur- 
nish him with the largest available proportion of nitrogenous material. 
Vegetables, except those which are really seeds, such as those of the 
leguminosge, or pulse tribe, contain but little fat. (Thompson.) 

The following-named vegetables are those in common use which con- 
tain the largest percentage of both starches and sugar : Potatoes (both 
sweet and white), yams, beans, lentils, corn, peas, carrots, parsnips, 
beets, turnips. 

Vegetable foods which are somewhat stimulant or pungent in their 
action are leeks, onions, garlic, herbs in general, mustard, mints, 
asparagus, and radishes. They increase the secretion of the saliva and 
gastric juice, and several are somewhat diuretic. 

Some vegetables are laxative on account of their special chemical 
composition. Such, for example, are spinach, tomatoes, and vegetables 
when fresh and well cooked. 

All vegetables which are eaten raw should be washed beforehand ; 
otherwise they may be contaminated with manure and other impuri- 
ties, or the excrements of domestic animals which have been roaming 
in the garden. The larvae of both tapeworms and round worms have 
been transmitted to man in this manner. Water from foul wells is 
sometimes used for sprinkling gardens, and it is possible for typhoid, 
cholera, or other noxious germs to be spread by this means when the 
vegetables are eaten raw. (Wood.) 

FRUITS. 

Speaking generally, fruits are composed largely of water, with 
sugars, a vegetable jelly called pectin, cellulose, and organic acids. 

The organic acids exist mainly in onions with alkalies, forming 
compounds which are readily split up in the system, leaving the alkalies 
to combine as carbonates or phosphates. (Bauer.) 

The most important acids are citric, malic, and tartaric, which 
exist in various quantities and combinations. Citric acid predominates 
in lemons, limes, and oranges ; tartaric acid, in grapes ; malic acid, in 
apples, peaches, apricots, gooseberries, and currants. Among the least 
acid of common fruits are peaches, sweet pears, sweet apples, bananas, 
and prunes; strawberries are moderately acid. 

Uses and Properties of Fruits. — The uses of different fruits are 
summed up as follows: — 

First, to furnish nutriment. 

Second, to convey water to the system and relieve thirst. 

Third, to introduce various salts and organic acids which improve 
the quality of the blood and react favorably upon the secretions. 

Fourth, as antiscorbutics. 

Fifth, as diuretics, and to lessen the acidity of the urine. 

Sixth, as laxatives and cathartics. 



848 Force Production — Energy from Food. 

Seventh, to stimulate the appetite, improve digestion, and give 
variety in the diet. 

Eighth, as special cures for certain diseases, like the grape-cure, 
although it is said their specific action is very doubtful. 

The fruits which afford the most nutriment are the banana, date, 
fig, prune, and grape. This is due to the large proportion of sugar 
which they contain. 

The fruits which contain the most water are watermelons, musk- 
melons, oranges, grape-fruit, lemons, shaddocks, and grapes. The 
antiscorbutic value of fruits is illustrated particularly by certain varie- 
ties which furnish abundant potash salts, as well as lime and magnesia. 
Ajnong these are to be mentioned apples, lemons, limes, and oranges. 

The diuretic influence of fruits is in part due to their water, but 
chiefly to their organic acids and salts, which stimulate the circulation 
and probably, also, the activity of the renal epithelium. 

The best fruits to offset constipation are fresh apples, figs, prunes, 
peaches, and berries. Dyspeptics must be careful to avoid eating all 
kinds of hard skins, seeds, or coarse-fibered fruits. 

Fruit Ripening. — As fruit ripens, it absorbs more and more 
oxygen, and the tannin and vegetable acids which it originally contained 
are altered, so that it becomes less astringent and more acid. The 
starch is more or less turned into levulose or glucose, and soluble pectin 
is formed. The aroma and taste of ripe fruits depend upon the rela- 
tive quantity of these different substances, together with various volatile 
ether and oils. The sour fruits have either more acid or less sugar, 
and in the sweet fruits there is a preponderance of sugar which masks 
the acid taste. The employment of fruits as a common article of daily 
diet is highly beneficial. 

Fruit Poisoning. — While fruits eaten daily and in proper modera- 
tion are very wholesome, if they are eaten too freely, or if they are 
either insufficiently ripe or overripe, soft, and decomposing, they un- 
dergo malfermentation in the alimentary canal, and are almost certain 
to cause diarrhea, with colicky pains, cramps, and sometimes nausea 
and vomiting. Severe attacks of gastritis may, especially in children, 
be produced by indulgence in unripe apples, pears, cherries, berries, 
etc., and even fatal choleraic diarrhea has been occasioned by the 
indiscriminate consumption of fruits which have strongly laxative 
action. After such fruit-poisoning, emesis should be excited if the 
patient is seen in time, and otherwise, if free purgation has not 
occurred, it is advisable to give a dose of castor-oil or other cathartics, 
to remove the irritating substances as soon as possible from, the ali- 
mentary canal. In bad cases, prolonged gastric fever may ensue. 

When to Eat Fruit. — Cooked fruits may be eaten with any meal ; 
but when fruit is eaten for special dietetic purposes, its effect is always 
more pronounced if it is taken alone, either at the commencement of 
meals or, better, between them. One often observes patients who can 
obtain no laxative effect from apples, figs, and other fruits eaten as 



Force Production — Energy from Food. 849 

dessert; but when they are taken at night into an empty stomach, 
or an hour before breakfast with a glass or two of cold water, a very 
pronounced favorable influence has been exerted upon the bowels. 

The poorest time for eating fruit is at the conclusion of a very 
hearty dinner, at which a considerable variety of food has already 
been consumed. Fruit is generally less wholesome when eaten out of 
its natural season. All fruits, such as berries, the seeds of which are 
eaten, are much less liable to produce intestinal irritation if taken 
with bread or other bulky starchy food. 

Fruit Soups. — In Germany fruit soups are more in vogue for 
general use than in this country, and they are often prescribed for 
fevers when diarrhea does not exist. UfTelmann directs that for mak- 
ing a fruit soup, one part of fruit to four or five of water may be 
used, and Bauer recommends soups "made of boiling fresh or dried 
fruits with water, with or without the addition of sugar, lemon peel, 
etc., and freed from the solid residue by pressure." 

Digestibility of Fruits. — Among the commoner fruits of easy diges- 
tion are grapes, oranges, lemons, cooked apples, figs, peaches > strawber- 
ries, and raspberries. Somewhat less digestible are melons, prunes, 
raw apples, pears, apricots, bananas, and fresh currants. Of course 
the digestibility depends very much upon the ripeness and freshness 
of the fruits as well as personal idiosyncrasy, and any classification 
can be only approximately correct. 

The most useful fruits for the sick are lemons, oranges, baked 
apples, stewed prunes, grapes, and banana meal (not the fruit pulp). 

Henry claims that pure lemon juice poured into the nose will 
often control epistaxis, or nose-bleed. 

NUTS. 

Nuts contain proteids with some starch and more or less fat. 
With the exception of the cocoanut, chestnut, almond, and English wal- 
nut, the varieties eaten in this country furnish but little nutriment. 
Their chief value is to stimulate the appetite and afford a variety in 
the diet. As a rule, they are not prescribed in invalid dietaries, but, 
with the exception of chestnuts and peanuts, they are allowed to dia- 
betics, and there are some few patients with dyspepsia whose slug- 
gish stomachs are stimulated into greater activity by eating a few 
parched or salted almonds or walnuts after a meal. 

FATS AND OILS. . 

Fats and oils contain but three elements — namely, carbon, oxygen, 
and hydrogen. In some fats like butter, but very little oxygen is 
present, and carbon and hydrogen compose the bulk of the substance. 
The amount of fat which from time to time is stored in the body is 
regulated to a greater degree than any other substance by muscular 
exercise, which, in active persons, always tends to prevent its accumu- 
lation. The storage of fat is favored by sleep as well as inactivity. 

54 



850 Force Production — Energy from Food. 

About one-fifth of the entire body weight is composed of fat, but 
only about a quarter of an ounce is contained in the blood. 

Fat is required to promote the earlier stages of growth and devel- 
opment of the organism, and there are also many forms of disease and 
degenerative changes which are accompanied by the increased accumu- 
lation or production of fat in and between the tissues and cells. It 
is impossible to live in perfect health without fatty food, and it is 
equally impossible to live long upon fat alone; for it soon disorders 
the digestion and causes absolute disgust. 

Uses of Fats. — The chief uses of fatty foods are : To furnish energy 
for the development of heat ; to supply force ; to serve as covering and 
protection in the body; to lubricate and make more plastic various 
structures of the body, and give rotundity to the form; to spare the 
tissues from disintegration ; for, although their combustion in the body 
results largely in the production of heat, they also take part to some 
extent in tissue formation ; also to serve for storage of energy. 

Digestibility of Fats. — Most of the fat used as food melts at the 
temperature of the body, which facilitates its digestion. 

Children often eat butter more readily than any other form of fat. 
As a rule, the stomach is less disturbed by animal than by vegetable 
fats taken in excess, and the former may be tolerated for a longer time. 
Overdoses of fat at any time are apt to give rise to the formation of 
irritating acids which cause nausea and vomiting, with possibly abdom- 
inal cramps and loose evacuations. Fat taken too liberally with other 
food ceases to be economical for the system, and becomes positively 
harmful. 

Since fat is exclusively digested in the small intestines, diseases 
of any part of the alimentary canal are contraindications for its use. 
The digestibility of all fats depends somewhat upon the cooked state. 
Many persons are nauseated or made dyspeptic by eating hot mutton 
fat who can eat the same with impunity when it is cold. In the latter 
condition it becomes more friable and, if thoroughly mixed in chew- 
ing with starchy food, or used as suet in the form of farinaceous pud- 
ding, it becomes very much more digestible. Animal fats have a 
higher nutritive power than those derived from vegetables, and liver 
fat, butter, and cream are the most serviceable of all. 

STIMULANTS AND BEVERAGES. 

The uses of stimulants and beverages that are classed under these 
headings are found to serve in one or more of the following ways : — 

1. To relieve thirst and introduce fluid into the circulation. 

2. As diuretics. 

3. As diaphoretics. 

4. As diluents of the food and of the waste material in the body. 

5. As stimulants of the nerves and other organs. 

6. As intoxicants. 

7. As demulcents. 



Force Production — Energy from Food. 851 

8. As tonics, and to promote digestion. 

9. As astringents. 
10. For nutrition. 

The effects of all beverages and stimulants are far more pronounced 
if they are taken into an empty stomach, which insures their prompt 
absorption. 

1. To relieve thirst, all fluids which are not too sweet may be 
used, but sour beverages, such as acid lemonade or raspberry vinegar, 
the effervescing carbonated waters, solution of potassium bitartrate, or 
dilute mineral acids in water, are generally the most acceptable. 

2. As diuretics, the mineral waters and carbonated waters hold 
the first rank. With many persons coffee is also an active diuretic. 
So are beer, gin, champagne, and, to a lesser degree, other forms of 
alcohol, and tea. 

3. As diaphoretics, hot spirits and water or hot tea may be used. 

4. As diluents of the ingested food and waste material of the 
body, the alkaline and carbonated effervescing or bland waters are the 
best. 

5. As stimulants of the nerves and other organs, the milder forms 
of alcoholic beverages, diluted spirits, tea, and coffee are used. 

6. As intoxicants, beers, ales, strong wines, champagne, and strong 
liquors are the most powerful agents. 

7. As demulcents, mucilaginous, farinaceous, and gelatinous bev- 
erages are used for fevers, etc., such as barley or oatmeal water, arrow- 
root and other light gruels, solutions of gelatin, flaxseed tea, etc. 
When taken hot they are soothing for coughs, and promote expectoration. 

8. For use as tonics and to aid digestion, may be mentioned malt 
extracts, ales, light wines, clarets, Burgundies, diluted brandy or 
whisky, chalybeate and arsenical waters, and alkaline waters drunk 
before meals. 

9. As astringents, red wines and tea are of chief importance. 

10. For nutrition, cocoa, chocolate, malt extract, and, because of 
the milk or cream added, tea and coffee. 

Of all these beverages, lemonade and orangeade are perhaps the 
most useful in the sick-room. These are agreeable, cooling, and refresh- 
ing in fevers, mildly diuretic, and beneficial in many ways. 



CHAPTEK LXVIL 
SIOK-EOOM DIETARY. 

COOKING. 

Toast-water. — Toast three slices of stale bread to a dark brown, 
but do not burn. Put into a pitcher; pour over them a quart of 
boiling water; cover closely, and let stand on ice until cold; strain. 
Wine and sugar may be added. 

Rice-water. — Wash a tablespoonf ul of rice ; put into granite sauce- 
pan with one quart of boiling water ; simmer two hours, when the rice 
should be softened and partially dissolved; strain; add a salt-spoon of 
salt ; serve warm or cold. May add sherry or port, two tablespoonf uls. 

Gum-arabic Water. — Dissolve one ounce of gum arabic in a pint 
of boiling water; add two tablespoonf uls of sugar, a wine glass of 
sherry, and the juice of a large lemon ; cool, add ice. 

Barley-water. — Wash two ounces (a wine-glassful) of pearl barley 
in cold water. Boil five minutes in fresh water; throw this water 
away. Pour on two quarts of boiling water ; boil down to a quart. 
Flavor with thinly-cut lemon-rind; add sugar to taste; do not strain 
unless at the patient's request. 

Egg-water. — Stir whites of two eggs into half a pint of ice-water 
or very cold well water without beating; add enough salt or sugar to 
make it palatable. 

Flaxseed Tea. — Flaxseed, whole, one ounce ; white sugar, one ounce 

' (heaping tablespoonf ul) ; liquorice-root, half ounce (two small sticks) ; 

lemon-juice, four tablespoons. Pour on these materials two pints of 

boiling water ; let stand in hot place four hours ; strain off the liquor. 

For Sterilized Milk. — (See Infant Feeding.) 

Peptonized Milk. — Cold process. In a clean quart bottle put one 
peptonizing powder (Fairchild's), or the contents of one peptonizing 
tube; add one teacup cold water; shake the mixture again. Place on 
ice. Use when required without subjecting to heat. 

Milk and Egg. — Beat one tumbler of milk with salt to taste; 
beat white of one egg till stiff; add egg to the milk, stir. May add 
a little mace, if desired. 

Peptonized Milk Toast. — Over two slices of toast pour one gill 
of peptonized milk (cold process) ; let it stand on the hob for thirty 
minutes. Serve warm or strain and serve the fluid portion alone. 
Plain light sponge cake may be similarly digested. 

Koumiss. — Take an ordinary beer bottle with shifting cork; put 
in it one pint of milk, one-sixth of a cake of Flieschmann yeast, or one 

(852) 



Sick-room Dietary. 853 

tablespoon of fresh lager-beer yeast (brewers'), one-half tablespoon 
white sugar reduced to syrup ; shake well and allow to stand in refrig- 
erator two or three days, when it may be used. It will keep in 
refrigerator indefinitely if laid on its side. Much waste can be saved 
by preparing the bottles with ordinary corks wired in position and 
drawing off the koumiss with a champagne tap. 

Wine Whey. — Put two pints of new milk in a saucepan, and stir 
over a clear fire until nearly boiling ; then add a gill (two wineglassfuls) 
of sherry, and simmer a quarter of an hour, skimming off the curd as 
it rises. Add a tablespoonful or more sherry, and skim again for a 
few minutes ; strain through coarse muslin. May use two tablespoon- 
fuls of lemon juice instead of wine. 

Junket. — Take half a pint of fresh milk, heated lukewarm; add 
one teaspoon essence of pepsin, and stir just enough to mix. Pour 
into custard-cups, let stand till firmly curded ; serve plain or with 
sugar and grated nutmeg. May add sherry. 

Egg Lemonade. — Beat one egg with a tablespoonful of sugar until 
very light ; stir in three tablespoonfuls of cold water ; add juice of 
small lemon; fill the glass with pounded ice and drink through a 
straw or glass tube. 

Egg-nog. — Beat the white of one egg and yolk separately; add 
to the yolk, while beating, one heaping teaspoonful of sugar ; add slowly 
one tablespoonful of whisky (old whisky), beating the yolk constantly; 
add the white slowly, beat thoroughly; lastly add two tablespoonfuls 
of cream (not too thick). 

Egg-nog Plain. — Scald some new milk by putting it (contained 
in jug or bottle) into a saucepan of boiling water, but do not allow it to 
boil. When cold, beat up a fresh egg with an egg-beater or a fork in 
a tumbler with a teaspoonful of sugar; beat to a froth, add a dessert- 
spoonful of brandy, and fill up the tumbler with scalded milk. 

Rum Punch. — White sugar, two teaspoonfuls ; one egg, stirred and 
beaten up ; warm milk, large wineglassful ; Jamaica rum, two to four 
teaspoonfuls ; nutmeg to taste. 

Champagne Whey. — Boil half pint of milk; strain through cheese- 
cloth ; add wineglassful of champagne. 

Peptonized Oysters. — Mince six large or twelve small oysters; 
add to them, in their own liquor, fixe grains of extract of pancreas with 
fifteen grams of bicarbonate of soda (or one Fairchild's peptoniz- 
ing tube). The mixture is then brought to blood heat, and main- 
tained, with occasional stirring, at that heat or temperature for thirty 
minutes. Then add one pint of milk and keep up the temperature 
ten to twenty minutes. Finally the mass is brought to a boiling point, 
strained, and served. Gelatine may be added, and the mixture served 
cold as a jelly. Cooked tomato, onion, celery, or other flavorings may 
be added at the beginning of the artificial digestion. 

Beef Tea. — Free a pound of lean beef from fat, tendon, cartilage, 
bone, and vessels ; chop up fine, put into a pint of cold water to digest 



854 Sick-room Dietary. 

two hours. Simmer on a range or stove three hours, but do not boil. 
Make up for the water lost by adding cold water, so that a pint of 
beef tea represents one pound of beef. Press the beef carefully, and 
strain. 

Beef Tea. — Chop line one pound of rump steak freed from fat 
and bone; put this in a fruit jar and close tight; put the jar in a 
vessel of cold water, and let it boil from four to six hours; strain, 
add salt and pepper to taste. Set the jar on a folded towel while it 
is boiling to prevent breaking. 

Beef Tea with Acid. — One and a half pounds of beef (round) 
cut in small pieces ; same quantity of ice, broken small. Let it stand 
in a deep vessel twelve hours. Strain thoroughly and forcibly through 
a coarse towel. Boil quickly ten minutes in a porcelain or granite 
vessel. Let cool. Add half a teaspoonful of acid phosphate to the pint. 

Mutton Broth. — Lean loin mutton, one and one-half pounds, 
including bone; water three pints. Boil gently till tender, add a 
pinch of salt, and onion to taste. Pour out broth into a basin ; when 
cold skim off the fat. Warm up as wanted. 

Chicken Broth. — Skin, and chop up small, a small chicken or 
half of a large fowl; boil it, bones and all, with or without a little 
mace, parsley, a tablespoonful of rice, and a crust of bread, in a quart 
of water, for an hour, skimming it from time to time. Strain through 
a coarse colander. 

Clam Broth. — Wash thoroughly six large clams in shell ; put in a 
kettle with one cup of water ; bring to a boil and keep there one min- 
ute. The shells open, the water takes up the proper quantity of juice, 
and the broth is ready to pour off and serve hot. 

Cream Soup. — Take a quart of good stock (mutton or veal), cut 
one medium-sized onion into quarters, slice three potatoes very thin, 
and put them into the stock with a small piece of mace ; boil gently 
for an hour ; then strain out the onion and mace. The potatoes should 
by this time have dissolved in the stock. Add one pint of milk, mixed 
with a very little corn flour to make it about as thick as cream. A 
little butter improves it. This soup may be made with milk instead 
of stock, if a little cream is used. 

Apple Soup. — Two cups of chopped apple; two cups of water; 
two teaspoons of corn-starch ; one and one-half tablespoons of sugar ; 
one salt-spoon of cinnamon, and a bit of salt, or it may be flavored 
with lemon juice. Stew the apple in the water until it is very soft ; 
then mix together into a smooth paste the corn-starch, sugar, salt, and 
cinnamon, with a little cold water ; pour this into the apple and boil 
for five minutes; strain it and keep hot until ready to serve. May 
serve with buttered toast or crackers. 

Raiv-meal Diet. — Scrape pulp from a good steak; season to taste 
with salt and pepper ; smear on thin slices of bread. 

Meat Cure. — Procure a slice of steak from top of round ; fresh 
meat without fat; cut the meat into strips, removing all fat, gristle, 



Sich-room Dietary. 855 

etc., with a knife. Put the meat through a mincer at least twice. 
The pulp must then be well beaten up in a roomy saucepan with cold 
water or skimmed beef tea to the consistency of cream. The right 
proportion is one teaspoonf ul of liquid to eight of pulp ; add black 
pepper and salt to taste; stir the mince briskly with a wooden spoon 
the whole time it is cooking over a slow fire or on the cool part of 
the covered range, till hot through and the red color disappears". This 
requires about one-half hour. When done, it should be a soft, smooth, 
stiff puree of the consistency of a thick paste. Serve hot. Add for 
first few meals the softly-poached white of an egg. 

Beef Juice (Bartholow). — Broil quickly some pieces of round or 
sirloin of a size to fit in the cavity of a lemon squeezer, previously 
heated by dipping in hot water. The juice, as it flows away, should 
be received into a hot wiue-glass, and, after being seasoned to taste 
with a little salt and cayenne pepper, taken while hot. 

Beef Essence ( Yeo-) . — Cut the lean of beef into small pieces, and 
place them in a wide-mouthed bottle securely corked, and then allow 
it to stand for several hours in a vessel of boiling water. This may 
be given to infants who can not take milk, in teaspoonful doses, and 
in larger quantities to adults. 

Chrystie's Beef Tea. — Macerate for one hour one pound of finely- 
minced lean beef in a pint of water containing fifteen grains of sodium 
chloride (table salt), and five drops of dilute hydrochloric acid, at 
100° Fahrenheit. Filter through cheese-cloth, and wash the residue 
with half a pint of fresh water. A child of two or three years may 
take two or three ounces daily. 

Anderson s Beef Tea with Oatmeal. — This forms a very nutritious 
food. Take two tablespoonfuls of oatmeal and two of cold water and 
mix them thoroughly; then add a pint of good beef tea which has just 
been brought to the boiling point. Boil together for five minutes, stir- 
ring it well all the time, and strain through a hair sieve. 

Ringer s Raw Meat Diet. — From two ounces of rump steak take 
away all fat, cut into small squares without entirely separating the 
meat, place in a mortar, and pound for five or ten minutes ; then add 
three or four tablespoonfuls of water and pound again for a few minutes, 
afterward removing all sinew or fiber ; add salt to taste. Before using, 
place the cup or jar containing the pounded meat in hot water until 
just warm. 

Or scrape the beefsteak with a sharp knife, and after removing 
all fat and tendon, if not already in a complete pulp, pound in a mor- 
tar. Flavor with salt and pepper. This may be made into a sand- 
wich between thin-sliced buttered bread or mixed with water to the 
consistency of cream. If preferred, the meat may be rolled into balls 
with a little white of egg and broiled for two minutes, or until the 
outside turns gray — just long enough to remove the raw taste. 

This diet is excellent for children with diarrhea, also for adults 
who suffer from irritable bowels or chronic diarrhea. 



856 Sick-room Dietary. 

Meat Biscuits (Parker). — Mix together, cook, and bake one pound 
of flour, one pound of meat, one quarter of a pound of suet, one-half 
pound potatoes, with a little sugar, onion, salt, pepper, and spices. 
Chop the meat very fine, add the flour, then the suet and mashed pota- 
toes, the seasoning, and water enough to make the dough as soft as it 
can be made to cut in small biscuits; cook (not too quickly). 

Ndurishing Soup (Ringer). — Stew two ounces of the best well- 
washed sago in a pint of water till it is quite tender and very thick; 
then mix it with half a pint of good boiled cream and the yolks of 
two fresh eggs. Blend the whole carefully with one quart of essence 
of beef. The beef essence must be heated separately, and mixed while 
bo'{,h mixtures are hot. A little of this may be warmed at a time. 

Chicken Jelly (Adams). — Clean a fowl that is about a year old, 
remove skin and fat; chop fine, bones and flesh; place in a pan with 
two quarts of water ; heat slowly ; skim thoroughly ; simmer five to 
six hours; add salt, mace, or parsley to taste; strain. Cool. When 
cold, skim off the fat. 

The jelly is usually relished cold, but may be heated. Give often 
in small quantities. 

Home-made Koumiss. — Boil fres^. milk, and when nearly cold put 
into quart bottles, leaving room to shake. Add half an ounce of 
crushed lump sugar, and a piece of Vienna yeast the size of a hazel- 
nut (i. e., twenty grains) ; cork with new corks, tie down ; keep cool ; 
lay the bottles horizontally, but shake twice daily. It is ready to drink 
on the sixth day, or earlier in hot, later in cold weather. 

Home-made Lime-water. — Pour two quarts of hot water over 
fresh, unslaked lime (size of a walnut); stir till slaked; let stand 
till clear, and bottle. Often ordered (by the physician) with milk 
to neutralize acidity of the stomach. 

Egg and Wine (Ringer).— Take one egg, half a glass of cold 
water, one glass of sherry, a little, a very little, nutmeg gra 
Heat the wine and water hot, but not boiling ; pour on the egg, stirring 
all the time. Put all into a porcelain-lined saucepan over a gentle fire, 
and stir one way till it thickens, but do not let it boil. Serve in a 
glass with crisp biscuits or toast. 

Lemonade with Egg. — The juice of four lemons, the rinds of two 
(grated), half a pint of sherry, four eggs, six ounces of loaf sugar, 
one pint and a half of boiling water. Pare the rind thinly (or grate 
it), put it into a pitcher with the sugar, and pour the boiling water 
on it. Let it cool, then strain, and add the wine, lemon juice, and 
eggs, previously well beaten and strained. Mix all together and it 
is ready for use. 

Savory Custard (Anderson's). — Add the yolks of two eggs to a 
cupful of beef tea, with pepper and salt to taste. Butter a cup or jam 
pot ; pour the mixture into it, and let it stand in a pan of boiling water 
till the custard is set. 

Milk for Puddings or Stewed Fruit (Ringer). — Boil a strip of 



Sick-room Dietary. 857 

lemon and two cloves in a pint of milk; mix half a teaspoonful of 
arrowroot in a little cold milk, and add it to the boiling milk; stir 
it till about the consistency of cream. Have ready the yolks of three 
eggs beaten np well in a little milk. Take the hot milk off the fire 
and as it cools add the eggs and a tablespoonful of orange-flower water ; 
stir it constantly till it is cool. Keep it in a very cool place till 
required for use. 

A Nutritious Gruel. — Beat an egg to a froth; add a wine-glass 
of sherry, flavor with a strip of lemon, a little sugar, and grated nut- 
meg. Have ready some rice, or arrowroot gruel, or oatmeal gruel, 
very smooth and hot, stir in the wine and egg y and serve with crisp 
toast. 

Caudle (Yeo). — Beat up an egg to a froth; add a glass of sherry 
and half a pint of gruel. Flavor with lemon peel, nutmeg, and sugar 
to taste. 

Arrowroot Blanc-mange (Einger). — Take two tablespoonfuls of 
arrowroot, three-quarters of a pint of milk, lemon, and sugar to taste. 
Mix the arrowroot with a little milk to a smooth batter; put the 
rest of the milk on the fire and let it boil ; sweeten and flavor it, stirring 
all the time, till it thickens sufficiently. Put into a mould till quite 
cold. Serve with cream flavored with a little nutmeg. 

Plain Oatmeal Gruel. — Two tablespoonfuls of oatmeal, one salt- 
spoonful of salt, scant teaspoonful of sugar, one cupful of boiling 
water, one cupful of milk. Mix the oatmeal, salt, and sugar together, 
and pour on the boiling water. Cook for thirty minutes ; strain through 
a fine wire strainer to remove the hulls, place again on the stove, add 
the milk, and when just to the boiling point, serve hot. May add 
to this one tablespoonful of thick cream if desired. 

Rice Gruel (Chambers). — Ground rice, two ounces; powdered cin- 
namon, quarter of an ounce; water, four pints. Boil forty minutes 
and add a teaspoonful of orange marmalade. 

Bice Milk (Andersen). — Boil about two tablespoonfuls of rice 
in a pint and a half of new milk, and simmer, stirring it from time to 
time till the rice is quite tender. Have ready some apples, peeled, 
cored, and stewed to a pulp, and sweetened with a very little loaf sugar. 
Put the rice round a plate and the apple in the middle, and serve. 

Bice Cream. — To a pint of new milk add a quarter of a pound 
of rice, a lump of butter the size of a walnut, a little lemon peel, a 
tablespoonful of powdered sugar. Boil them together for five min- 
utes; then add half an ounce of isinglass which has been dissolved, 
and let the mixture cool. When cool, add half a pint of good cream 
whisked to a froth, mix together, and set it for a time in a very cool 
place, or on ice. When used, turn it out of the basin into a dish, 
and pour fruit juice around it, or some stewed apples, prunes, peaches, 
pears, or strawberries may be served with it. 

Bice Cream. — Two tablespoonfuls of rice, two cups of milk, one 
salt-spoonful of salt, two tablespoonfuls of sugar, two eggs. Wash the 



858 Sick-room Dietary. 

rice several times in cold water; cook it in a double boiler with the 
milk until the grains will mash. Three hours will generally be required 
to do this. Should the milk evaporate, restore the amount lost. When 
the rice is perfectly soft, press it through a coarse soup strainer or 
colander into a saucepan, return it to the fire, and while it is heating, 
beat the eggs, sugar, and a pinch of salt together until very light. 
When the rice boils, pour the eggs in rather slowly, stirring lightly 
with a spoon for three or four minutes, or until it coagulates, and the 
whole is like a thick, soft pudding; then remove from the fire, and 
pour it into a dish. By omitting the yolks and using the whites of 
the eggs only, a delicate cream is obtained. 

S Malt (Ground) and Rice Pudding (Yoe). — Stir an ounce of 
ground malt into a pint of boiling milk; strain through a sieve, and 
add the milk to two ounces of well-soaked rice. Mix well, and stand 
for ten minutes in a warm place, then bake for an hour. 

Cracker Gruel. — Two tablespoonfuls of cracker crumbs, one scant 
salt-spoon of salt, one scant teaspoon of sugar, one cup of boiling water, 
one cup of fresh milk. To make the cracker crumbs, roll some crackers 
on a board until they are fine. (Water crackers are good, cream 
crackers are better. ) Mix the salt and sugar with the crumbs ; pour 
on the boiling water ; put in the milk, and simmer it for two minutes. 
The gruel does not need long cooking, for the cracker crumbs are 
already thoroughly cooked. Serve without straining it. 

Indian Meal Gruel. — Two tea spoonfuls of corn-meal, one table- 
spoonful of flour, one teaspoonful of salt, one teaspoonful of sugar, 
one quart of boiling water, one cup of milk. Mix the corn-meal, flour, 
salt, and sugar into a thin paste with cold water, and pour into it 
the boiling water. Cook it in a double boiler for three hours. No, 
less time than that will cook the corn-meal thoroughly. Then add the 
milk, and it is ready now to serve. 

Milk Porridge. — Milk, eight pints ; flour, twelve ounces ; water, 
three pints. (This is a hospital recipe, and may use only one-fourth, 
etc.) The flour to be used for milk porridge should be previously 
prepared by being tied up closely in a bag and boiled four or five 
hours. It then can be grated to a powder, which should be mixed 
into a smooth paste with cold water. Add to the milk the prescribed 
quantity of water, and stir in the flour, with a little salt. Let it boil 
ten minutes, stirring all the time. Serve hot, 

FothergilVs Amylaceous Food. — Of rice, well washed, of arrow- 
root, of tapioca, and pearl barley, take of each an ounce, add two 
quarts of water, and boil down to a quart; then flavor with candied 
eringo or any flavoring desired. 

Barley Jelly (Eustace Smith). — Put two tablespoonfuls of washed 
pearl barley into a pint and a half of water, and slowly boil down to a 
pint; strain, and let the liquid settle into a jelly. Two teaspoonfuls 
of this dissolved in eight ounces of warmed and sweetened milk are 
enough for a single feeding, and such a meal may be allowed twice a day. 



Sick-room Dietary. 859 

Almond Cakes for Diabetics (Seegen). — Take of blanched sweet 
almonds a quarter of a pound, beat them as fine as possible in a stone 
mortar ; remove the sugar contained in this meal by putting it into a 
linen bag and steeping it for a quarter of an hour in boiling water 
acidulated with vinegar (apple vinegar) ; mix this paste thoroughly 
with three ounces of butter and two eggs. Next add the yolks of 
three eggs and a little salt, and stir well for some time. Whip up the 
whites of three eggs and stir in. Put the dough thus obtained in 
greased moulds and dry by a slow fire. 

Port Wine Jelly (Ringer). — Put into a jar one pint of port wine, 
two ounces of gum arabic, two ounces of isinglass, two ounces of 
powdered white sugar candy, a quarter of a nutmeg grated fine, and 
a small piece of cinnamon. Let this stand closely covered all night. 
The next day put the jar into boiling water and let it simmer until 
all is dissolved, then strain, let stand till cold, and then cut into small 
pieces for use. 

To Make a Flaxseed Poidtice. — The water should be boiling 'not 
in a vessel suitable to the size of the poultice to be made. Stir into 
the boiling water, slowly, enough ground flaxseed to the consistency of 
soft porridge (that is, so it will spread smoothly). Cook rapidly for 
two or three minutes. Should it become a thick paste, add a little 
boiling water to thin it down to the desired consistency. Spread be- 
tween cheese-cloth, and apply as hot as can be borne. 

Bread-and-miJk poultice is made with bread crumbs stirred in 
boiling fresh milk in the same manner as the flaxseed meal is used, as 
prescribed above. 



CHAPTEE LXVIII. 
ASTHMA, COLDS, HAY-FEVEK, TONSILLITIS. 

ASTHMA. 

Definition. — A paroxysmal disturbance of the respiratory organs,, 
sometimes periodic, with entirely or comparatively free respiration 
during the intervals between the attacks. 

Etiology. — Asthma is considered to be often congenital, as it fre- 
quently occurs in certain families in which neurasthenia, hysteria, 
neuralgia, and gout are common. 

Salter thinks that hereditary influences are a predisposing cause, 
since in more than two-fifths of two hundred and seventy cases he finds 
distinct traces of inheritance, direct or lateral, immediate or remote. 

Males are thought to be more liable than females, because they 
are more exposed to the various exciting causes, — the weather and 
its vicissitudes, for instance. 

It is more common in the upper classes than in the lower, probably 
because of the nervous system being more sensitive. 

Chief among the exciting causes is bronchitis, either simple or as 
a manifestation of whooping-cough or measles. A sharp attack of 
bronchitis in a child may give rise to asthma or difficult breathing, 
greatly resembling asthma. The exciting causes appear to be inti- 
mately connected with climate. 

Residence in a given locality may be helpful to the one and 
injurious to the other. The influence of climate does not depend upon 
the degree of moisture or the range of temperature, but oftener upon 
peculiarities of the individual, since a moist climate and cold weather 
are beneficial to some and injurious to others. That which is sure to 
bring it on in one may have no appreciable influence over another. 
Among these are dust and fog, smoke, fumes and vapors from animals, 
odors from flowers. In certain cases the attack of asthma is regarded 
as the result of a reflex irritation of the nerves of respiration from 
disease of the stomach or of the intestinal tract, hence dyspeptic or 
nervous asthma. 

Symptoms. — In some cases there is nothing suggestive of an 
attack of asthma, for instance, being suddenly wakened out of a sound 
sleep at night with sharp attack of difficult breathing (a paroxysm of 
dyspnoea), a sense of thoracic constriction, a suffocating feeling. 
Patient sits upright, and breathes violently, but not rapidly, the 
inspiration usually being short and deep, and the expiration pro- 

(860) 






Asthma, Colds, Hay-fever, Tonsillitis. 861 

longed. In other cases inspiration may be comparatively easy and ex- 
piration especially labored. . The attack of dyspnoea may continue for 
minutes or hours ; relief often comes with the expulsion of the sputum. 
The cough is at first slight and dry, but becomes paroxysmal and for- 
cible in the efforts to raise secretion, the presence of which in the 
lungs is often made evident by moist rales. The sputum is viscid, 
grayish white, scanty, or profuse. As the breathing becomes easier, 
the patient feels exhausted, falls asleep, and awakes apparently well, 
at the most somewhat fatigued. Other attacks are likely to occur in 
the course of successive days or at intervals of a number of days or 
weeks, during which there is more or less cough between the attacks. 
Longer or shorter intervals of freedom from it, lasting months or 
years, may then follow, or the attacks are of such frequent occurrence 
that pulmonary emphysema (an excessive dilatation of the air cells, 
admitting air into the areola tissues), and eventually dilatation of the 
heart, results. 

Diagnosis.— This may be difficult. Difficult breathing, affecting 
both lungs, is an important characteristic of bronchial asthma, by 
means of which other causes of recurrent attacks of difficult breath- 
ing, except in emphysema, chronic bronchitis, and cardiac asthma, 
may be excluded. In cardiac asthma the difficult breathing (dys- 
pnoea affects both inspiration and expiration. Rales are absent un- 
less pulmonary oedema occurs as a complication. The attack usually 
appears during the evening or night, often waking out of a sound 
sleep. The child sits up in bed, is restless, and instinctively seeks to 
overcome the struggle for breath by grasping the bedclothes or some 
other object, thus facilitating the action of the accessory muscles of 
respiration. The patient may have had symptoms of a trifling cold 
the previous day. The face is pale, and has an anxious look; the skin 
is moist and cool ; there is no fever ; the pulse is rapid and often irreg- 
ular; the respiration is slow and labored, expiration much prolonged. 
Cough, if present, is short and dry. Towards the end of the attack 
a little tough and viscid white mucus may be expelled. The fit, after 
lasting a variable time, may go nearly or quite as rapidly as it came, 
the patient falling asleep, and waking in the morning about as well 
as usual. In case of bronchial or catarrhal cases, the cough is less 
dry and more frequent. A fresh attack of bronchitis brings the 
asthma anew. 

Prognosis. — This is better, so stated, in children than in adults. 
A strong hereditary predisposition does not in itself preclude recovery j 

Treatment. — Is prophylaxis, or the prevention of the affection in 
those presumably predisposed, and the prevention of the recurrence 
of attacks in those who have already experienced them, and palliative 
treatment of the paroxysm itself, as the attack sometimes depends 
upon a removable cause, especially upon the presence of polypi or, 
other obstructive lesions of the nose. The urine also should be exam- 
ined, to prevent the overlooking of uraemic origin. As an attack may 



862 Asthma, Colds, Hay-fever, Tonsillitis. 

be due to inflammation of the lungs or bronchials, a favorable climate 
should be sought; when it is possible, a warm, dry climate is best in 
some cases, and others must have a warm, moist climate. Each indi- 
vidual case should be studied in choosing a climate suited to its 
special condition. 

The general hygienic management should be that of chronic 
bronchial catarrh, though, in children, the use of meat or other highly- 
nitrogenous foods should be restricted. 

No diet which produces indigestion or flatulence is suitable for 
the asthmatic. If, however, an almost purely meat diet is the only 
one digested, it should be the only one allowed. Furthermore, the 
heavy meal should always be taken in the middle of the day, and the 
supper should be made very light, so that the digestion may be com- 
pleted by bedtime. In children, a simple and highly-nutritious diet, 
and careful attention to house ventilation, both of living and of sleep- 
ing rooms, should be combined. The child should be guarded against 
whooping-cough and measles; with this, woolen clothing should be 
worn. 

Enlargement of the bronchial glands, or bronchitis, calls for cod- 
liver oil and the iodide of iron — the syrup of the iodide of iron if 
the tongue is clean and the digestion fairly good, from three to five 
drops for a child eight or ten years old. Arsenic is of value in some 
cases, but should be prescribed by the family physician. Potassium 
iodide is beneficial in many cases, and should be given for about three 
months, in ascending doses up to the point of tolerance. (Wood.) The 
dose for an adult is from two to seven grains, after meals, given in 
milk or in syrup of sarsaparilla. In syphilitic cases as high as ten 
grains in milk after meals, three times a day, is especially useful. 
Bromide of sodium and bromide of ammonium with antipyrine are 
prescribed for nervousness in asthmatic cases. Ten grains of bromide 
of sodium, with five grains of antipyrine, every four or six hours till 
quiet. The inhalation of compressed air in the pneumatic cabinet is 
highly spoken of by some writers. 

Palliation. — The treatment of the paroxysm varies according as 
the special case is of the spasmodic type or of the catarrhal variety, 
and in the latter according to the amount of secretion. Chloroform 
and ether arrest the fits, but only temporarily, the attack returning as 
the paroxysm passes off. Chloral, with potassium bromide, five grains 
of each, well diluted in water or milk for an adult, renders excellent 
service, and may be given to children according to the age. One to 
two grains may be given to a child eight years old. Nitre-paper is a 
time-honored remedy, the inhalation of the fumes through a paper 
cone. Inhalation of the iodide of ethyl is highly recommended by 
See; ten minims can be safely used for a child. (Shattuck, M. D.) 
Trousseau recommends belladonna, and lobelia is highly spoken of 
by some, The patented powders and pastilles which are used among 
the laity, and which, it must be confessed, are often efficacious, con- 



Asthma, Colds, Hay-fever, Tonsillitis. 863 

tain nitre, stramonium, and lobelia. Berkart recommends pilocarpine, 
one-eighth to one-tenth of a grain being given to children (hypo- 
dermically) five years of age. 

In catarrhal cases, in children, an emetic such as ipecac will clear 
out the bronchial tubes, relax spasms, and materially relieve the 
breathing. No true asthmatic paroxysm can withstand the depressant 
effect of nausea. 

Quick relief is often obtained by sipping very hot water till 
the paroxysm subsides; then take from five to eight grains of Dover's 
powders, with three grains of quinine. An eighth to one-fourth of 
a grain of calomel is one dose for an adult ; it may be given to chil- 
dren, according to the age. Usually one dose is sufficient to relieve 
the paroxysm. Should the fit return before the powders have any 
effect, the sipping of hot water may be repeated, with a little whisky 
added to the water. On waking up after taking the Dover powder, 
the patient may drink a cup of black coffee, not too weak, to relieve 
the unpleasant effect of the powder. 

ACUTE COLD IN THE HEAD, RHINITIS, ACUTE NASAL CATARRH, CORYZA. 

Etiology. — Acute cold in the head is often the result of exposure 
to draughts of air, to cold or wet weather. The irritation from bac- 
teria is suggested by the occurrence of epidemics of acute nasal catarrh. 
Taking cold from exposure to cold and damp is said to be due to 
bacterial action, the growth of the bacteria being favored by the dis- 
turbance in the circulation in the nostrils produced by the exposure. 

Symptoms. — Frequent sneezing and increasing obstruction of the 
nostrils are the significant symptoms of acute cold or rhinitis. These 
are frequently preceded by chilly sensations, followed by slight fever. 
There is at first a profuse watery secretion from the nasal mucous 
membrane; later it is slimy, and finally opaque yellow. The sense 
of smell and taste is impaired, if not lost for a time. 

Treatment. — Acute coryza does not necessarily require very close 
confinement to the house, but in delicate children and very old people 
it may be necessary to put the patient to bed. At the beginning of 
the cold a full dose of quinine (from -G.ve to ten grains, with about four 
grains of Dover's powder, and a half grain of calomel and soda) for 
an adult will usually arrest or modify the attack. Quinine should be 
taken in two-grain doses three times a day throughout the course of 
the attack. Snuff powder for the nose, made as follows, is very 
effective in breaking up an acute cold in the head: — 

1^: Bismuth subnitrate ^j 

Talcum '. gj 

Morphias sulphas gr. iiss 

Pulv. gum camphor gr. ijss 

M. ft. Chart, in powders, No. xii. 

Sig. : Divide the powder ; snuff it up the nose night and morning. 



864 Asthma, Colds, Hay-fever, Tonsillitis. 

Keep the bowels moving, not too freely, with castor oil or syrup 
of rhubarb, or some mild laxative. 

To break up a general cold, that is to say, where the entire body 
or part of the body are suffering from aching pains in the limbs or 
pain in the chest, calls for quinine and whisky, to be taken every four 
hours (quinine in two-grain capsules and a tablespoonful of whisky). 
Keep the bowels moving daily, and a dose of calomel at the onset of the 
cold aids in breaking up the trouble (one to two grains at bedtime, with 
a little soda, followed with a heaping teaspoonful of salts on the fol- 
lowing morning). Confinement in a warm room is essential in most 
all cases till the affection is overcome. Should a cough result from the 
cpld, the following cough mixture will give quick relief : — 

fy. Tr. hyoscyami 3ij 

Ammon. muriate 3j 

Syr. scillse 3jss 

Camph. Tr. opii 3jss 

Syr. prunus Virg Eiv 

Spt. frumenti, q. s if viij 

M. et sig. : For cough and cold. 

Teaspoonful to be taken every two or three hours till well of the 
cold. 

HAY-FEVER. 

Synonyms. — Hay or rose cold, summer or autumnal catarrh, hay- 
asthma, etc. 

Definition. — Hay-fever is an affection of the naso-pharyngeal 
mucous membrane, recurring annually and periodically, characterized 
by irritation and redness of, and flux from, the mucous membranes of 
the eyes, nose, throat, and bronchi. 

Etiology. — This affection has been designated June cold, hay- 
asthma, etc., and its origin is attributed to the pollen of certain 
grasses and cereals. In 1872 Dr. Morrill Wyman, of Cambridge, in 
common with many members of his family, a sufferer, published his 
highly interesting and important monograph, based on an analysis of 
eighty-one cases, in which was made conspicuous the more serious 
autumnal catarrh, closely allied to June cold in method of origin and 
symptoms. Essential in the production of both is a nervous tempera- 
ment, exposure to the exciting causes, and excessive sensitiveness of 
the nasal mucous membrane. The nervous temperament is often 
inherited. The inhalation of various irritants often produces an 
attack of coryza or asthma in sufferers from the periodical catarrh. 
Hay-fever is considered to be a pure neurosis in all cases in which there 
are no notable nasal lesions persistent between the paroxysms. 

Symptoms and Course. — The date on which the symptoms begin 
to recur each year is in some cases absolutely definite, though in the 
large majority there is a variation of a few days or more. In some 
there is a prodromal stage, lasting one or two weeks, during which 



Asthma, Colds, Hay-fever, Tonsillitis. 865 

there may be more or less nervous irritability, or alternating sensa- 
tions of heat and cold, or a feeling of lassitude. In other cases there is 
no prodromal stage. 

As the first symptoms, at or about the stated dates the patient 
notices an itching in the mouth, nose, or throat, and a sense of fulness 
or weight in the frontal region. In the course of a day or two there 
is an itching of the eyelids, which are puffy, and the nasal mucous 
membrane becomes swollen, reddened, and so irritated that a violent 
attack of sneezing results, which is accompanied by a profuse watery 
discharge from the nostrils, often continuing throughout the day; 
there are also redness and swelling of the face in the morning, and 
impairment, or even loss, of the special senses of smell, taste, and hear- 
ing. Itching of the scalp and of the skin of the back or chest, a tend- 
ency of the skin to become easily excoriated, and, when excoriated, to 
heal slowly, and more or less general depression of the system, with 
lack of appetite and quickening of the pulse-rate, are often experienced 
during this period, which lasts from ten days to two weeks. The irri- 
tation now extends to the bronchial mucous membrane, exciting a short, 
annoying cough, which results in but little expectoration, and that of 
transparent, glairy mucus. The cough is worse in dry than ill damp, 
wet weather, at night than during the day, and increases for a week or 
ten days. During the fourth week the early symptoms are apt to 
diminish ; but the cough persists, and asthma, if it comes at all, now 
appears, intensifying the misery of the night. During the fifth and 
sixth weeks there is a gradual decline of the symptoms, and the patient 
soon after regains health and strength, until the time of periodical 
recurrence comes round again the following year. 

Prognosis. — Dr. Wyman says that as regards expectation of life, 
this is good. Hay-fever patients seem to live as long as those who are 
free from the infirmity. 

Treatment. — "It is maintained by various specialists that local 
treatment will suffice to cure a large percentage of cases, — a statement 
which, however, still needs confirmation. " (Wood.) The local 
curative treatment consists in the persistent use of the galvanic cur- 
rent, applied in the same manner as in cases of nasal catarrh, and in 
the surgical removal of deformities, the destruction by cauterization 
of sensitive portions of mucous membrane, and the use of various local 
applications. A specialist of great skill in the use of instruments is 
required in this disease. Quinine is useful. Dover's powder (five 
grains), with one-fourth of a grain of calomel at bedtime, is beneficial 
in some cases. It may be given according to the age of the patient. 

The local palliative treatment consists in the employment of cer- 
tain drugs. Wood recommends a solution of potassium bromide (ten 
grains to the ounce of water), which may at first be carefully applied 
to sensitive spots, afterward more freely used, and also increased a 
little in strength. The free use of cocaine in hay-fever by the means 
of a spray (four per cent solution) will almost invariably give tem- 

55 



866 Asthma, Colds, Hay-fever, Tonsillitis. 

porary relief. The excessive violence of the asthmatic paroxysms of 
hay-fever may call for hypodermic injections of morphine with 
atropine; but their use is attended with danger of the narcotic habit. 
The climatic treatment of hay-fever is said to be almost invariably 
successful in preventing the attacks during the treatment. A certain 
degree of elevation above the sea is often effective. When it is in the 
power of the patient to do so, it is well to change locality, going to 
the seashore or a mountain resort, whichever experience has proved to 
give immunity to the particular individual. It is desirable to go shortly 
before the time of the expected attack, and to remain at least six 
weeks, after which time the danger for that year is practically over. 
The leading resorts are the Cat skills, portions of the Green and Adi- 
rondack Mountains, Cresson, Pennsylvania, and Deer Park, Mary- 
land. The White Mountain resorts are Bethlehem, Jefferson, Gor- 
ham, the Twin Mountain House, and the Glen. Beach Haven and 
Eire Island are noted American resorts. 

TONSILLITIS, OK QUINSY. 

Acute Tonsillitis. — As described, tonsillitis is an acute inflamma- 
tion of the tonsil or tonsils, or acute quinsy, which may be superficial, 
and may terminate in resolution, suppuration, or chronic enlarge- 
ment. 

Acute Superficial Tonsillitis. — This disease is often due to sud- 
den or prolonged exposure to cold or wet, or to improper food, and 
an overheated, vitiated atmosphere. A healthy child complains more 
or less /weariness and general malaise. It seems fretful, drooping, 
~nd out of sorts. Frequently there are headache, nausea, or vomiting, 
chiliy sensations, and some elevation of temperature. The bilious con- 
dition may be very marked; the coated tongue and stomachic disturb- 
ance may last during several days ; with these symptoms the child com- 
plains of slight heat or pain in the throat and difficulty of swallowing. 
The pain at first is complained of at the angle of the jaw. Here there 
is often slight swelling of the lymphatic ganglia; there is pain on 
pressure in this region, indicating where the inflammation exists. 

When there is marked swelling of the tonsils, the voice assumes 
a nasal intonation. There is often occasional cough, with frequent 
painful expectoration of viscous and stringy mucus, which collects in 
the throat. If the child is very young, it swallows the mucus. There 
is thirst ; the breath is foul ; the bowels are constipated. The urine 
is small in quantity, high-colored, and loaded with urates. The breath 
is accelerated, the pulse rapid and full. The fever rises rapidly, and 
in a few hours may reach 102° or 103° Fahrenheit. The pulse 
ranges from one hundred and ten to one hundred and thirty per 
minute. 

Course, Duration, and Termination. — In mild cases of tonsillitis 
convalescence usually begins in three or four days, and the swelling 
of the tonsils disappears in the course of a week. In severest cases, 



Asthma, Colds, Hay-fever, Tonsillitis. 867 

to which the name quinsy is especially applied, an abscess forms in the 
inflamed tonsil. On the third or fourth day of the tonsillitis, the 
enlarged tonsil becomes soft and fluctuant. The abscess may break 
suddenly, usually into the mouth or the pharynx, when the local 
symptoms often at once disappear, and rapid relief follows. 

Treatment. — The first indication in the treatment of acute ton- 
sillitis in children is to obtain a free evacuation of the bowels. Give 
from half a grain to one or two grains of calomel in tablet form 
(according to the age of the patient) dissolved (or not) in a little 
water, and followed in three hours by a dessert-spoonful of Rochelle 
salts in half a tumbler of water. Small doses of sulphate of magnesia 
(Epsom salts), with quinine two grains, repeated three or four times 
in twenty-four hours, are also very useful. 

The following is a good formula: — 

1£: Magnesia sulph giij 

Qninse sulpli gr. vi 

Acid, sulphurici dil gtt. xx 

Syr. zingiberis. . ^ss 

Syr. liquorice, ad jfiij 

M. sig. : Give a dessert-spoonful every three hours to a child 
three or four years of age. 

When the bowels have been relieved, one-fourth to one-half drop 
doses of aconite may be given. Put one drop of aconite in two or four 
teaspoonfuls of water, and of this give a teaspoonful every half hour. 
This will very soon diminish temperature, and lower the pulse and 
respiration, while it increases the action of the skin, and thus promotes** 
speedy relief. r 

Cohen 1 advises the use of the ammoniated tincture of guaiacum 
topically, in the form of a gargle, with cinchona, honey, and chlorate 
of potassium. The salicylate of sodium, given in two to four-grain 
doses in milk, according to the age -of the patient, will soon cut short 
the disease, and prevent suppuration. Poultices of flaxseed applied 
very hot every fifteen minutes at the outset of the disease, will very 
often aid in cutting it short. They should be applied for several hours 
in succession. When the poultices are removed, keep the throat pro- 
tected with cotton batting or a silk handkerchief. 

During the acute stage of tonsillitis, the child should be confined 
to bed, and allowed light diet, such as milk, eggs, gruel, soups, milk 
toast, rice pudding, custard, etc. In young children a glass of port- 
wine, given quite at the beginning of the attack, is said often to have 
power to abort it. (Eustace Smith.) 

Locally, gargles are often used with comfort. 



Pepper's System of Medicine, vol. ii, p. 388. 



868 Asthma, Colds, Hay-fev&r, Tonsillitis. 

Vk. Thymol . , gtt. ij 

Acid carbol. liq TT^xx 

Boracis . . . . sj 

Glycerini 3vi 

Aquse, ad 3vi 

M. sig. : Use as a gargle, or with the atomizer, every hour or two. 

In quinsy all that can be done to avoid the formation of pus is 
to cleanse the throat with a very dilute solution of hydrogen peroxide 
or thymol. Use a mouth-wash as above prescribed, and poultice the 
throat as already advised. If pus forms, it should be evacuated as soon 
aj3 possible. If the abscess is in the soft palate, a little above and on 
the outside of the margin of the tonsil, the incision should be through 
the soft palate, just outside of, and parallel to, the anterior pillar, and 
in the neighborhood of the line of the upper margin of the tonsil. 
When the tendency is for the pus to escape through the crypt of the 
tonsil, the incision should be made into the tonsil, as near as possible 
to the natural outlet of the pus. 

For the relief of pain, codine, sulphonal, or trional should be pre- 
scribed in doses suited to the case, for sleeplessness. Of codine, give 
from one-fourth to one-sixth of a grain to a child ten to fifteen years of 
age; of sulphonal, two to four grains to a child eight to twelve years 
of age. The dose may be repeated every six hours for restlessness. 

Gude's peptomanganate should be given for constitutional treat- 
ment, as prescribed on the bottle; doses suited to the age of the 
patient. 



GLOSSARY 



Abduction: The movement which sepa- 
rates a limb or other part from the 
axis of the body. 

Acetabula: Cavity cup-shaped, situated 
in the os innominatum. 

Acne; An eruption occurring most fre- 
quently on the face. 

Adduction: The action by which parts 
are drawn towards the axis of the 
body. • 

Adynamic: Appertaining to debility of 
the vital powers. 

Adynamic: Debility of the vital organs. 

Ag'lobulism: A diminution of the 
amount of hemogloblin in the blood. 

Albuminuria: A condition of the urine 
in which it contains albumin. 

Amenorrhoe'a: Suppression of the men- 
ses. 

Amnii; Membrane around foetus. 

Amorphos : Having no determined 
form. 

Ampulla: A membrane bag shaped like 
a leather bottle. 

Amyloid; Resembling starch. 

Anemia; Bloodlessness. 

Anesthesia: Privation of sensation. 

Anasarca: Dropsy of subcutaneous cel- 
lular tissue. 

Aneurism: A soft, pulsating tumor 
arising from dilatation or rupture 
of an artery. 

Angina: Any inflammatory affection of 
the throat. 

Angioma: A tumor composed mainly 
of new blood-vessels. 

Ankylosis: An affection in which there 
is great difficulty, or even impossi- 
bility, of moving a joint, which re- 
mains in a constant state of flexion. 

Anu coccygeal: Pertaining to the anus. 

Anodynes: Those medicines which re- 
lieve pain. 

Anomalous ; Irregular. 

Anorexia: Want of appetite. 

Anterior: Situated before. 

Anteflexion; Bending before. 

Anthrobom etry: Measuring the dimen- 
sions of the different parts of the 
body. 

Antiphlogistic: Opposed to inflamma- 
tion. 

Antipyretic: A febrifuge; a medicine 
to allay fever. 



Antipyretic: Opposed to fever. 

Antipyretics; Efficacious in preventing 
fever. 

Anus; The posterior opening of the ali- 
mentary canal. 

Aphasia; Sleeplessness. 

Aphonia; Privation or loss of voice. 

Aphthous: Pertaining to sore mouth. 

Aplasia; Defective or arrested growth 
of tissue. 

Apposition; Adding an artificial part. 

Arborescent: Resembling a tree. 

Arte' Holes: Small arteries. 

Arthritis; Inflammation of joints. 

Articulation: The union of bones with 
each other ; a movable articulation. 

Arytenoid: Two small cartilages at the 
top of the larynx. 

Ascaridae ; Intestinal worms. 

Asepsis; Preventing putrefaction. 

Asphyxia: A stoppage of the pulse. 

Aspirate: Drawing off the fluid con- 
tents of tumors with an instru- 
ment called an aspirator. 

Aspirator; Instrument for evacuating 
fluid from tumors. 

Astragalus: A short bone situated at 
the superior and middle part of the 
tarsus, where it is articulated with 
the tibia. 

Astringent: Puckering. 

Atelectasis: Imperfect dilatation. 

At'omy: Want of tone. 

Atrium: An auricle of the heart. 

Atropine: A poison remarkable for its 
power in dilating the pupil of the 
eye. 

Atresia: Growing together. 

Ausculta'tion: Detecting disease by 
sound. 

Axilla; The armpit. 

Bacillus; A genus of bacteria. 

Bacteria: Minute vegetable organisms 
found in decayed matter. 

Bifurcate: To divide into two branches. 

Blennorrha gia: Relating to gonorrhea. 

Bougie: A rubber sound. 

Bouillon: A nutritious liquid food made 
by boiling beef or other meat in 
water. 

Branny: Consisting of bran. 

Bryant's Triangle: A triangle having for 
its hypothenuse, or longest line, a line 
drawn from the anterior-superior 

(869) 



870 



Glossary. 



iliac spine to the great trochanter 
of the thigh bone. 

Buccal; Pertaining to the mouth or 
cheek. 

Bulbar: Pertaining to the medulla ob- 
longata. 

Bulla: A vesicle or an elevation of the 
cuticle containing a transparent 
watery fluid. 

Cachetic: A morbid condition of the 
body. 

Calcane'um: The largest of the tarsal 
bones ; that which forms the heel. 

Calculus: A concretion on any part of 

the body. 
^Capsule (has several meanings) : A 
membranous, fibrous, and elastic 
bag or capsule, of a whitish consist- 
ence, which surrounds the joints. 

Carcinoma: Incipient cancer. 

Carpal: Belonging to the carpus, or 
wrist, as carpal joints. 

Cartilage: A solid part of the animal 
body, of medium consistence be- 
tween bone and ligament. In adults 
it exists only in the joints, at the 
extremities of the-ribs, etc. 

Casein: Cheese. 

Catalepsy: An affection generally con- 
nected with hysteria. 

Catanienial : Relating to menses. 

Catheter: A curved instrument intro- 
duced into the bladder through the 
urethra for drawing off the urine. 

Catheterization: To introduce the cath- 
eter to probe. 

Cauterize: To burn. 

Cephalitis: Inflammation of the brain. 

Cerebritis: Inflammation of the cere- 
brum. 

Cerulean: Dark colored, blue. 

Cervix-uteri; The neck of the womb. 

Chalybeate : To impregnate with iron. 

Chlorosis: A disease affecting young 
females near the period of puberty. 

Choane: The infundibulum of the brain. 
Cholagogue : A substance which pro- 
motes the flow of bile. 

Cholesterin: An inodorous, insipid sub- 
stance in white, shining scales. 

Chorea; A nervous disease. 

Chorion; The thin, transparent mem- 
brane which surrounds the foetus in 
utero. 

Cicatricial: Relating to a seam. 

Cicatrice: A pellicle formed over a 
wound, subsequently contracted into 
a scar. 

Cirrhosis: A yellow coloring matter, 
sometimes secreted in the tissues. 

Clavicle: The collar bone. It is shaped 
like the letter S, and is situated 
transversely at the upper part of the 
thorax. 

Clitoris: The erectile organ of the fe- 
male. 



Climacteric : The time when menses 
cease. 

Colotomy: The operation of cutting into 
the colon. 

Coma; A state of profound insensibil- 
ity. 

Comatose; Relating to or resembling 
coma. 

Concomitant: Attending; conjoined. 

Condyle: An articular eminence round 
in one direction, flat in the other. 

Condyloma: Soft, fleshy excrescences 
of an indolent character. 

Congenital; Produced or existing at 
birth. 

Contusion: An injury which presents no 
loss of substance, and no apparent 
wound. 

Cor'acoid: A short, thick process situ- 
ated at the anterior part of the up- 
per margin of the scapula; it re- 
sembles the beak of a crow. 

Corium: The deep layer of mucous 
membrane beneath the epithelium. 

Cornu: A horny excrescence. 

Coronoid: A sharp process situated at 
the superior part of the ulna, and 
forming a part of the hinge of the 
elbow joint. 

Coryza; Inflammation of membrane lin- 
ing of the nose. 

Costal: Relating to a rib. 

Crypt; The simple tubular glands of the 
small intestines. 

Cuboid: Relates to one of the bones of 
the tarsus. 

Cul-de-sac ; A blind alley. 

Curetting; Cleansing. 

Cyanic: Blue stage of a disease. 

Cyanosis: From insufficient aeration of 
the blood, the body becomes blue. 

Cyanotic: A more or less livid color at 
the surface of the body due to im- 
perfect circulation. 

Cystinuria; Urine, cystinic. 

Cystitis: Disease of bladder. 

Cystocele : A tumor. 

Cys'toscope: A catheter. 

Cystot'ic: Relating to contraction of the 
heart. 

Cystotomy: Cutting into the bladder 
for any purpose. 

Decidual: Relating to a falling off from 
the uterus. 

Decubitis: Assuming a horizontal pos- 
ture. 

Decubitus; An attitude assumed in ly- 
ing down. 

Decussate; Crossed; intersected. 

Defecation; The act of extruding ex- 
crement. 

Defervescence: Decrease of fever or 
feverish symptoms. 

Deglutition: The act of swallowing 
food. 



Glossary. 



71 



Dentition ; Teething. 

Desquamation: Exfoliation, or scaling 
off of the scarf-skin. 

Diachylon; A plaster originally com- 
posed of juices of several plants, 
but now made of an oxide of sil- 
ver, lead, and oil. 

Diaphoretic : A medicine which prompts 
perspiration. 

Diaphoretics: Medicines which excite 
diaphoresis, or perspiration. 

Diaphysis: Anything that separates two 
bodies. 

Diathesis; A predisposition to some dis- 
eases rather than others. 

Dietetic; Rules, regulations, kind, and 
variety of food eaten. 

Dilatation; The enlargement of some 
physical organ. 

Diluents; Medicines augmenting fluid- 
ity of the body. 

Diuretic; Medicine that increases the 
secretion of the urine. 

Diuretics; Medicines which increase the 
secretion of the urine. 

Dorsum: Posterior part of the trunk, 
extending from the inferior and pos- 
terior region of the neck as far as 
the loins. 

Duodenitis: Inflammation of the duo- 
denum. 

Dyscrasia: A bad habit of the body. 

Dyspnoe'ic: Short-breathed. 

Dysuria; Difficulty of passing the urine. 

Ec'chymose: To discolor by the produc- 
tion or effusion of blood beneath the 
skin. 

Eclamp'sia: Convulsion, as the convul- 
sions of children. 

Eczema: An inflammation of the skin, 
attended with considerable disturb- 
ance. 

Effusion: The pouring out of blood or 
of any fluid into the areolar mem- 
brane, or into the cavities of the 
bodv. 

Embolism: Obstruction produced by a 
clot or foreign body brought from 
a distance. 

Emetics: Substances capable of produc- 
ing vomiting. 

Emollient: An external softening or 
soothing application to allay irri- 
tation. 

Empyema: A collection of blood or pus 
in some cavity of the body. 

Empyscma: A tumor caused by intro- 
ducing air into the areolar tissue. 

Endemic; Peculiar to a locality or class 
of persons. 

Endocarditis: Inflammation of the en- 
docardium. 

Endocervi'tis: Inflammation of the neck 
of the uterus. 



Endometritis: Inflammation of the 
uterus. 

Endometrium: Lining membrane of the 
uterus. 

Endoscope ; An instrument for inspect- 
ing internal parts. 

Enemata: Injections. 

Enteric: Intestinal. 

Epigastric ; Pertaining to the upper and 
anterior part of the abdomen. 

Episas'triiim: Over the belly. 

Epilepsy; Loss of consciousness at- 
tended with little or no muscular 
disturbance. 

Epileptiform: Of the nature of parox- 
ysms of the brain. 

Epiphy'sis: Any portion of a bone sepa- 
rated from the body of the bone by 
a cartilage, which becomes converted 
into bone by age. 

Epistaxis; Bleeding from the nose. 

Epithelial: Of or pertaining to epithe- 
lium. 

Epithelioma: A morbid condition of 
the thin epidermis ; cancerous. 

Epithelium: The thin skin covering a 
membrane. 

Erotic; Melancholy, that which is pro- 
duced by love. 

Erotomania; A species of mental alien- 
ation caused by love. 

Eructation; A belching of wind from 
the stomach. 

Erythema; A diseabe of the skin. 

Eschar: A crust or scab. 

Etiological: Inquiring into causes. 

Etiology: The doctrine of causes of dis- 
eases. 

Exacerbation: An increase in the symp- 
toms of a disease. 

Exanthematous ; Characterized by efflo- 
rescence of the skin. 

Excised; Cut out or off. 

Excoriated ; Abraded; galled. 

Excoriation; A slight wound remaining 
in the skin. 

Exfoliation; Throwing off of dead por- 
tions of scales. 

Exsected : Cut off or away. 

Extravasation; Effusion; emptying or 
forcing a fluid out of its proper ves- 
sels. 

Farinaceous: Consisting of meal and 
flour. 

Fascia; A band, sash, or fillet, especially 
in surgery ; a bandage. 

Fascia: A band, sash, or fldet, especially 
mists to an aponeurosis and to a 
muscle. 

Fastigium: The extreme point or front 
of the head. 

Feces: Matter excreted. 

Febricula: A slight and short fever, es- 
pecially when of obscure causation. 



872 



Glossary. 



> 



Febrile; Relating to a fever. 

Femur: The thigh; the strongest and 
longest bone in the body. 

Fibroid: Like a tumor. 

Fibula: The long, small bone situated 
at the outer part of the leg. 

Fimbria: The fringed extremity of the 
Fallopian tube. 

Fissure: A fracture in which the bone 
is cracked as in fracture ; also a sort 
of chap observed on the hand, etc. 

Fistula; A permanent abnormal opening 
into the soft parts, with constant 
discharge. 

Fixed: To fasten. 

Flatus: Flatulence. 

Fontanel; The opening of the head. 

Fornix; A medullary body in the brain. 

Fructifying: Fertilizing. 

Fundus; The base of an organ that 
ends in a neck. 

Ganglion; A knot-like enlargement in 
the course of a nerve ; it is also 
applied to tumors situated some- 
where on a tendon. 

Gastrodyn'ia: A pain in the stomach. 

Genital; Pertaining to generation, or to 
the generative organs. 

Gestation; The period of pregnancy. 

Ginglymus: Like a hinge; admitting of 
motion in two directions only. 

Gonorrheal: Relating to a flow from the 
membranes of the urethra. 

Gynaecol' o gist: One skilled in science of 
diseases peculiar to women. 

Hematocele: A tumor formed by 
the blood. 

Hemato'ma: Bloody tumor on the 
scalp of a newborn child. 

Hematozo'a: Entosia in the blood. 

Hematuria: Voiding of blood by urine. 

Hemastat'ics: Stopping or preventing 
hemorrhage. 

Hematosis: The formation of blood in 
general. 

Hemiphle' 'gia: Paralysis of one side of 
the body. 

Hemophilic: A congenital morbid con- 
dition characterized by a tendency 
to bleed immoderately. 

Hemorrhoids : Common piles. 

Hepatic; Like or pertaining to the liver. 

Hernia: Rupture. 

Hermaph'rodism: Relation to union of 
both sexes in one. 

Her pes: An eruption on the skin in 
small, distinct clusters. 

Horripilation; Chilliness preceding a 
fever, accompanied by bristling of 
the hair all over the body. 

Humerus: The cylindrical irregular 
bone of the arm, the upper extrem- 
ity of which has a hemispherical 
head connected with the scapula. 



Hydatid' if or m: HaVing the form of 
water vesicles within the head. 

Hydrocephalus: A collection of water. 

Hydronephrosis: An accumulation of 
its secretion in the kidneys. 

Hydrosalpinx: An accumulation of 
liquid in a Fallopian tube. 

Fly' men: The semilunar, parabolic, or 
circular fold situated at the outer 
orifice of the vagina in virgins. 

Hyperesthesia: Over-sensitive. 

Hypererethis'ia: Excessively irritable. 

Hyperplasia; An increase in or excessive 
growth of the normal elements of 
any part. 

Hypertrophicd ; An enlargement of a 
part of the body from excessive nu- 
trition. 

Hypertrophy ; A state of a part in which 
the nutrition is performed with 
greater activity. . 

Hyperpyrexia: A high degree of fever. 

Hypodermic : That which is under the 
skin. 

Hypogastrium; The lower part of abdo- 
men. 

Hypostasis; A morbid deposition in the 
body ; sediment. 

Hypostatic : That which is deposited at 
the bottom of a fluid. 

Hysterectomy ; The excision of the 
uterus. 

Ichorous: Thin, watery serous. 

Icterus: A disease the principal symp- 
toms of which are yellowness of the 
skin and eyes, with white faeces and 
high-colored urine. 

Idiopathic: Primary affections and their 
symptoms. 

Ileo-caecal: Of or pertaining to the 
ileum and caecum. 

Iliac: Name given to arteries, muscles, 
relating to the flanks, etc. 

Ilium: The largest of the three bones 
which constitute the os innomina- 
tum in the foetus and child. 

Immobile: Immovable. 

Impeti'go: A cutaneous pustular erup- 
tion not attended with fever, usu- 
ally a kind of eczema with pustula- 
tion. 

Impaction: A collision; a fracture with 
depression of some fragments and 
projection of others externally. 

Imperforate; Not perforated. 

Incapsulation; Putting one inside of an- 
other. 

Incontinent; Unable to restrain natural 
discharges or evacuations. 

Incubation; Hatching. 

Induration: The hardness which super- 
venes occasionally in an inflamed 
part. 

Infiltration; Passage of blood into an 
areolar membrane. 



Glossary. 



873 



Infravag'inal: Below the vaginal junc- 
tion. 

Inhibitory: Prohibitory; to hold in re- 
straint. 

Inspis'sant: Aay remedial agent that 
renders the blood thicker, directly 
or indirectly. 

Interstitial: Applied to that which is in 
the interstices of an organ, preg- 
nancy, etc. 

Intussusception: Generally it is the up- 
per part of the small intestines, 
which is received into the lower. 

Inversion: To turn. 

Ischium: The lower part of pelvis. 

Intermenstrual: Occurring between 
menstrual periods. 

I'tis: Inflammation. 

Jactation: Extreme anxiety; excessive 
restlessness. 

Koumiss or Kumyss : A beverage used 
in families of the people of Tartary. 
It resembles sour buttermilk, with- 
out being greasy. 

Kumiss: A slightly alcoholic drink 
prepared from milk with sugar and 
yeast. 

Labium: Lip. 

Laceration: Tearing. 

Lactation: The secretion and yielding 
of milk. 

Laminae: Scales of bone. 

Laparotomy: Incision into the abdo- 
men. 

Lesion: Any morbid change in struc- 
ture of organs. 

Leucorrhoe'a: Flow of a white, yellow- 
ish, or greenish mucus. 

Leucomaine : A nitrogenous organic 
base of alkaloid produced in liv- 
ing animal tissues as a result of 
their activity. 

Levator A'ni: Lifter of the anus. 

Lithemia: An excess of uric acid in 
the blood. 

Litharge: A yellowish-red substance 
obtained as an amorphous powder. 

Lumbar: Belonging or having reference 
to bone, muscles, and nerves. 

Lumbricoid: Resembling an earth- 
worm. 

Lvmphadeni'tis: Inflammation of the 
lymphatic gland. 

Lysis: The gradual recession of a dis- 
ease, which is operated insensibly. 

Magnum Os (great bone) : The largest 
bone of the carpus. 

Malaise: Indisposition. 

Malleolar: Belonging or relating to the 
ankles. 

Mammae: The breasts; udder. 

Massace: The art of applying inter- 
mittent pressure and strain to the 
muscles and other tissue; to knead. 

Masti'tis: Inflammation of the breast. 



Masturbation : Excitement of genital 
organs by the hand. 

Maternis morbi; A place to receive 
pregnant women. 

Meatus: A passage or canal. 

Meatus urinarius: The external orifice 
of the urethra. 

Meconium: That passed by infants 
after birth which accumulated in 
the intestines during pregnancy. 

Mediastinum: A membranous space 
formed by a double reflection of the 
pleura, extending from the spine to 
the posterior surface of the sternum. 

Meningeal: Relating to the covering of 
the brain. 

Meningitis: Inflammation of the mem- 
brane of the brain. 

Menopause: Stopped menses. 

Menorrhagia: An excessive flow. 

Mcnorrhca: A difficult or painful flow. 

Mesenter'ica : Reflexion of the peri- 
toneum. 

Metabolism: The process by which cells 
assimilate the material carried to 
them. 

Metastasis: A change in the seat of a 
disease. 

Meteorism : Tympanitis. 

Metritis: Acute inflammation in the 
womb. 

Micrococcus : A producing disease; 
bacterium. 

Micturition: The act of making' water. 

Migraine: Pain confined to one-half the 
head. 

Mobile: Movable. 

Morbific; Causing or introducing dis- 
ease. 

Myeli'tis: Inflammation of the spinal 
marrow or its membranes, indicated 
by deep-seated, burning pain in the 
spine. 

Myocarditis: Inflammation of the mus- 
cles of the heart. 

Nae'vus: Spots on children when first 
born. 

Narcosis: Privation of consciousness; 
narcotic poisoning. 

Narcotism ; State of being under the 
influence of narcotics. 

Nelaton's Line: This line is taken from 
the anterior-superior iliac spine to 
the most prominent part of the 
ischial tuberosity. 

Neoplasm: A new formation of tissue, 
the product of morbid action. 

Nephritis: A disease of the kidneys. 

Neurosis: A generic name for diseases 
supposed to have their seat in the 
nervous system. 

Neurasthenia; Nervous debility or ex- 
haustion. 

Neuropathic; Belonging to disease of 
nerves. 



874 



Glossary. 



Neurotic; Disease of the nervous func- 
tion. 

Nodular; Relating to the teeth. 

Nucha; The back or upper part of the 
neck. 

Nymphomania: Morbid or uncontrol- 
lable sexual desire. 

Obturator: A name given in anatomy 
to several parts connected with the 
obturator foramen. 

Occipital: Along the back part of the 
head. 

Occlusion: A total or partial close of a 
passage. 

Oedema: Swelling produced by an ac- 
cumulation of a serous fluid in the 
areolar tissue. 

Oidium albicans: A genus of fungi 
which form a floccose mass of fila- 
ments on decaying matter ; aph- 
thaphyte and parasite. 

Olecranon: The head or protection of 
the elbow ; a large process of the 
upper extremity of the ulna, on 
which we lean. 

Oligomenorrhea: Flowing too little. 

Oophorectomy: Excision. 

Orchitis: Hernia humoralis. 

Os-interum: Opening of the womb. 

Os: Mouth. 

Ostium: The opening a door or gate, of 
the heart, for example. 

Otitis-media: Inflammation of middle 
ear. 

Ovarian: Relating to the ovaries. 

Ovulation : Formation of ovules ; dis- 
charge of ovum. 

Oxalates; Salts of oxalic acid. 

Oxyu rides: Pin-worms. 

Papula: A small acuminated elevation 
of the cuticle, with an inflamed 
base. 

Parametric; Situated near the uterus. 

Paraplegia: Palsy of lower half of the 
body on both sides. 

Parenchymatous: Relating to the pa- 
renchyma of an organ. 

Parotitis; Inflammation of the parotid 
gland. 

Parturition: Child-bearing; delivery. 

Pathopenefic: Producing disease. 

Pathological; Science which treats of 
disease. 

Pathology: The branch of medicine 
whose object is the knowledge of 
disease. 

Pa tulous : Spreading. 

Pederast' 'y: The crime against nature: 
sodomy. 

Ped' uncle: A flower stalk. This term 
has been applied to different pro- 
longations, or appendices, of the 
encephalon; to the brain and cere- 
bellum. 



Ped'unculatc; Having a pedicle; grow- 
ing on a pedicle. 

Pemphigus: A somewhat rare skin dis- 
ease, characterized by the develop- 
ment of blebs upon different parts 
of the body. 

Peptonize; To convert into peptone. 

Percussion: Vibratory shock. 

Perineum: The space at inferior region 
of trunk, between the ischiatic tu- 
berosities, anus, and genital organs. 

Peristalsis: Vermicular movement. 

Peritoneal: Relating to smooth mem- 
brane lining the abdomen. 

Peritoneum: Lining membrane of inner 
wall of abdominal cavity. 

Peritonitis: Inflammation of the peri- 
toneum. 

Perityphlitis: Inflammation of caecum, 
appendix, and connective tissue. 

Pertussis: A violent convulsive cough; 
returns by fits; whooping-cough. 

Pessary; A uterine support. 

Phalanges: A name given to small bones 
of the fingers and toes. 

Phimosis: Prepernatural narrowness of 
the opening of the prepuce. 

Phlegmon; Inflammation of areolar tis- 
sue. 

Phlegmonous: Relating to phlegmon, or 
inflammation of areolar tissue. 

Phlogistic: Inflammatory. 

Phthisical: Relating to progress of 
emaciation. 

Phthisis; A wasting or consumption of 
the tissues. 

Physiognomic ; Pertaining to the face. 

Placenta: The organ of attachment of a 
vertebrate embryo, or foetus, to the 
wall of the uterus, or womb, of the 
female. 

Plethora: Overfulness. 

Polymorphous: Exhibiting many forms. 

Polvpus; A pear-shaped tumor. 

Polyuria: Diabetes. 

Popliteal: That which relates to the 
ham. 

Portio dura: A small, white fasciculus. 

Posterior: Moving; coming after. 

Praecor'dia: Front part of the thoracic 
region. 

Primipara; A female who brings forth 
her first-born. 

Prodromic : Precursory. 

Proglottis: One of the free, or nearly 
free, segments of a taneworm. 

Prolapsus: The falling down of a part 
through the orifice with which it is 
naturally connected. 

Pronation: Rotation from without in- 
wards. 

Protean: Assuming different shapes and 
forms. 

Pruritus: Heat; itching. 



Glossary. 



875 



Psoas: Lumbar; the posae muscles. 

Psoriasis: A cutaneous affection, con- 
siting of patches of rough, amor- 
phous scales. 

Pubescent: Relating to the pudenda, 
age, etc. 

Pubic: A name given to the genital or- 
gans, as well as to other parts of 
the body. 

Pyaemia: A form of blood-poisoning 
and purulent contamination of the 
blood. 

Pyeti'tis: Inflammation of the kidneys. 

Pyrexia: The febrile condition. 

Pyriform ; Pear-shaped. 

Quotidian: Daily. 

Rachial'gia: Pain, colic. 

Rachitis: Inflammation of the spine. 

Radius: One of the bones of the fore- 
arm. 

Rale: Noise produced' by air in passing 
through mucus, of which the lungs 
are unable to free themselves. 

Rancid: Having a rank taste or smell. 

Recrudes cence: The state of becoming 
raw or exacerbated again. 

Reduce: To restore a displaced part to 
the proper relative situation. 

Resonance : A return of sound. 

Resolution: Removal or disappearance, 
as of a disease. 

Revulsion: The act of turning the prin- 
ciple of a disease from the part in 
which it seems to have taken its 
seat. 

Rhinitis: Inflammation of the nose; 
coryza. 

Rigidity: Great stiffness of fiber, or want 
of suppleness. 

Rupture: To break or burst. 

Rugae: Wrinkles. 

Sacculate: Pouches, as in the colon. 

Salicylate: A salt of salicylic acid. 

Salicylic: Acid now made from phenol. 

Salpingitis; Inflammation of the FaK 
lopian tube. 

Saprophitic: Feeding on decayed mat- 
ter. 

Sacro-coccygeal: Relating to the sa- 
crum and coccyx. 

Sacroiliac: Relating to the sacrum and 
ilium. 

Sacrum: The bone which forms the pos- 
terior part of the pelvis, and is a 
continuation of the vertebral col- 
umn. 

Satyria'sis: An irresistible desire to 
have frequent connection with the 
female. 

Scaphoid: A name given to several parts. 
This bone is situated at the fore- 
part of the astragalus and inner 
part of the foot. 

Scapula: The shoulder-blade. 



Scarification; Slight scratching. 

Sclerosis; Thickening with condensa- 
tion. 

Sclerosed; Hard, enduration. 

Scrotum: The bag containing the tes- 
ticles. 

Scybala; Hard fcecal matter discharged 
in hard lumps. 

Sebaceous; Pertaining to or secreting 
fat. 

Seborrhea; A morbidly increased dis- 
charge of sebaceous matter upon the 
skin. 

Secrete; To separate from the blood. 

Sedatives: Medicines which directly de- 
press the vital forces. 

Semilunar: Having the shape of a half 
moon. 

Senile: Relating to old age. 

Septic; That which produces putrefac- 
tion. 

Sepsis; Poisonous putrefaction. 

Septicaemia: A morbid condition of the 
blood produced by septic matters. 

Septum; A partition. 

Sequelae; A morbid phenomena left as 
the result ot a disease. 

Sessile: Not stalked or peduncled. 

Sigmoid; Shaped like sigma or letter S. 

Sinapisms: Mustard plasters. 

Sinciput: The upper part or half of the 
head ; the dome of the skull. 

Slough; To separate dead matter from 
living tissue. 

So' porous: Causing sleep. 

Sor'dcs: Foul matter that collects on the 
teeth and tongue in low fever. 

Spermatozo'id: Resembling a sperma- 
tozoa. 

Sphincter: An annular muscle that 
closes an opening. 

Sporadic: Occurring singly, or apart 
from other things of the same 
kind. 

Spore: A reproductive body in crypto- 
gamous plants. 

Sputum: That which is expectorated. 

Stasis: Stagnation. 

Stenosis: A narrowing of an opening. 

Sternum: A flat, azygous, symmetrical 
bone, situated at the fore part of the 
chest. 

Steth'oscope: An instrument for detect- 
ing disease by sound. 

Stomatitis: Inflammation of the folli- 
cles of the mouth. 

Stroma: Substance of anargan, usually 
a tissue. 

Struma ; Scrofula. 

Styloid: Shaped like a peg or pin. 

Styptic: Stopping blood, astringent. 

Sub-involution: Imperfect restoration 
of the uterus after delivery. 

Sulce: A furrow; a groove. 



876 



Glossary. 



Supinated: The movement in which the 
forearm and hand are carried out- 
ward, so that the anterior surface 
of the latter becomes superior. 

Suppositories : Solid medicine intro- 
duced into the rectum. 

Suppuration: Running matter. 

Supine: Lying on the back. 

Syco'sis: A pustular eruption upon the 
scalp or bearded part of the face; 
a fungous ulcer. 

Symphysis: A union of bones. 

Syncope: A fainting or swooning. 

Synovia: A fluid resembling the white 
of an egg. 

Synovitis: A term applied at times to 
inflammation of the synovial mem- 
brane. 

Syphilis: An infectious disease com- 
municated by coition. 

Talipes varus: Lameness in the foot. 

Tampon: A bung; a plug. 

Tarsus: The posterior part of the foot. 

Tendo A chillis: A fibrous cord, more 
or less round, long, or flattened. 

Tendonous: Having the nature of ten- 
dons. 

Tenesmus: Frequent vain desire to 
evacuate. 

Tension: A stretching or straining, as 
when the tissues of a part are dis- 
tended by the afflux of fluids. 

Thallus: Matted together; interweav- 
ing. 

Therapeutics: The discovery and ap- 
plication of remedies for disease. 

Thrombi: Round, bluish tumors. 

Thrombosis: Coagulation. 

Thyroid: Shaped like an oblong shield; 
shape of a folding door. 

Tibia: The largest bone of the leg, 
situated on the inner side of the 
fibula. 

Toxaemic: Poisoning state of the 
blood. 

Toxic: Poisonous. 

Toxicological: The science which treats 
cf diseases due to poisons. 

Trachelorraphy: Plastic operation for 
restoring a fissured cervix uteri, or 
perineum. 

Tracheotomy: A surgical operation on 
the trachea. 

Traumatism: The condition of organs 
affected by a grave wound. 

Trochanter : Anatomists have given the 



names great and little trochanter tj 
two processes at the upper extrem- 
ity of the femur. 

Turgescence : Superabundance of hu- 
mor in a part. 

Tympanitic : Distended with wind. 

Ulna: Name of one of the bones of the 
forearm. 

Umbilicus: The depression or mark in 
the median line of the abdomen 
which indicates the point where the 
umbilical cord is separated from the 
foetus. 

Unctious: Greasy; fatty. 

Unilateral: Pertaining to one side. 

U'rachus: It is regarded as a kind of 
suspensory ligament of the bladder. 

Ure'ter: The canal that carries urine 
from the kidneys to the bladder. 

Urethra: The excretory duct of the 
urine. 

Urethritis: An inflammation of urethra. 

Urticaria: Nettle-rash; hives. 

Uterus: Womb for lodgment of the 
foetus from conception till birth. 

Vaginismus : A spasmodic action of the 
sphincter muscle at the opening of 
the vagina. 

Vaginitis: Inflammation of the vagina. 

Varicella: A specific contagious disease, 
usually of childhood ; chicken-pox. 

Variola: Smallpox. 

Vascular: Relating to veins. 

Vasomotor: That which causes move- 
ment in vessels. 

Velpeau Bandage: Name of a bandage. 

Venesection : Blood-letting. 

Varicose: Irregularly-swollen or en- 
larged veins. 

Vertigo: Dizziness or swimming of the 
head. 

Vesication: The process of vesicating 
or raising blisters. 

V e sic o -vaginal: Relating to the bladder 
and vagina. 

V esiculosc : Having bladdery vesicles. 

Villous: Containing villi. 

Violaceous: Resembling violets in 
color; bluish purple. 

Vulva: A longitudinal opening between 
the projecting parts of the external 
organs of generation in the female. 

Wheal: A ridge, or elevation of skin, 
produced by a rod or whip; such 
elevations as are seen in uticaria. 

Zoster: Shingles. 



INDEX 



Abdominal Enlargements 33 

Abscess, Psoas yy 

Anal 211 

Pelvic 74 

Symptoms 75 

Treatment 75 

Acidity of Urine 189 

Acne (skin disease) 723 

Alkalinity of Urine 189, 190 

Amenorrhea (not flowing) 30 

Acquired 30 

Atrophy .- 30 

Obesity 30 

Treatment 128, 129 

Anaemia (lack of blood) 159 

Anaesthesia (loss of feeling) 208 

Anhydrosis (absence of sweating) . . .726 
Ankylosis (stiff joints) . . . .300, 310, 794 

Antidotes (for poisons) 765,766 

Antiflection (to bend) of Womb... 105 
Anteversiou (to turn) of Womb.... 103 

Diagnosis and Treatment 104 

Anus (opening of the rectum) 208 

Fissure of 209 

Symptoms and Treatment 209 

Abscess of 211 

Appendicitis yy 

Symptoms 81 

Diagnosis 82 

Chronic 83 

Treatment 84 

Asteatosis (deficiency of the secre- 
tions of the sebaceous gland 

of the skin) 725 

Diagnosis, Treatment 725 

Asthma 860 

Etiology 86o* 

Symptoms 860 

Diagnosis 861 

Prognosis 86; 

Treatment 861 

Asphyxia (syncope of new-born 

child) 319 

Treatment 319 

Bladder Diseases 185 

Functional Derangements 187 

Inflammation of 188 

Diagnosis 190 

Treatment 191, 192 

Tuberculosis of 104. 196 

Diagnosis, Treatment 197 

Vesico-Vaginal Fistula 197 

Diagnosis, Treatment 198 

Stone in the Bladder 199 

Symptoms 199 

Diagnosis, Treatment 199 



Tumors in Bladder 200 

Symptoms 200 

Diagnosis, Treatment 201 

Washing Out 194, 195 

Biliary Diseases (jaundice) 650 

Catarrh of Bile Duct 650 

Symptoms, Treatment 650 

Round Worms in 651 

Biliary Tract 651 

Treatment 651 

Boils (furuncles) 730 

Treatment 732 

Breasts 250 

Diseases of 250 

Inflammation of 251 

Abscess of 252 

Symptoms, Treatment 253 

Chronic Abscesses 253 

Symptoms, Treatment 254 

Hypertrophy of Breasts 255 

Treatment 255 

Breathing in Children 284 

Irregularities of, in Children. . .280 

Bronchial Phthisis (consumption) . .285 
In Children 285 

Bronchial Pneumonia 285, 286 

Bryant's A, C, D, Ilio-Femoral Tri- 
angle 782 

Cancer (varieties of) 76 

Sarcoma 181 

Carcinoma 181 

Epithelioma 181 

Cardiac and Pulmonary System .... 283 

Care of Child at Birth 313, 314 

In Abnormal Conditions. . .315, 316 

Treatment 317, 318 

Syncope of New-born Child.... 319 

Injuries of 321 

Treatment 322, 323 

Catarrh, Nasal 712 

Cellulitis (inflammation of cellular 

tissues around the womb) .... 67 

Chronic Cellulitis 68 

, Dependent upon Salpingitis (sal- 
pinx, a tube) 68 

Change of Life 126 

Chicken-pox 525 

Symptoms, Treatment 525 

Chilblains 728 

Causes 728 

Diagnosis, Treatment 728 

Children's Diseases 256 

Diagnosis of 256 

State of General Development, 

Weight, Dentition, Walking. .261 
Mean Height and Weight 262 

(877) 



878 



Index. 



Examination of Head and Neck 

265, 266 

Temperature 267 

Pulse 269 

The Cry 270 

Dropsy . . 273 

General Pain and Pain in Limbs. 274 

Family History 275 

Heredity 275 

Rheumatism 277 

Malformations 277 

The Nervous System 278 

Consumption 278 

Meningitis 281 

Scarlet Fever 2S2 

^ Breathing 283 

Pulmonary and Cardiac 284 

Symptoms 284, 285 

Bronchial Consumption 2S5 

Pneumonia 285 

Pleurisy -87 

Digestive System 28S 

Tonsillitis 290 

Itching of the Nose and Anus, 

Grinding of the Teeth 290 

Urinary Disorders 291 

Gravel 291 

Diabetes 291 

Wetting the Bed 292 

Irritation or Stricture in Little 

Boys 292 

Vulvitis and Purulent Discharge 

from Little Girls 292 

Chlorosis (green sickness) 154 

Diagnosis, Treatment 154 

Cholera Infantum 628 

Symptoms. Treatment 628, 629 

Hygienic Treatment 630 

Acute Inflammatory Condition of 

the Bowels 630 

Symptoms 631 

The Dyspeptic Form 631 

Complications 631 

Nervous Symptoms 632 

Vomiting 632 

Acute Catarrhal Condition of 

the Bowels 632 

Ulceration of 633 

Complications of 633 

Diagnosis 634 

Treatment 634 

Dietetic Treatment 634 

Medical Treatment 035 

Local Treatment 636 

Hygienic Management of the 

Child 638 

Cholera, or Asiatic Cholera 572 

Definition 572 

Symptoms 572 

Incubation Period 572 

First Stage 573 

Second Stage 573 

Third Stage 574 

Fourth Stage 574 

Complications 574 



Diagnosis 575. 

Treatment 577, 578 

Cold 863 

Etiology 863 

Symptoms 863 

Treatment 863 

Rhinitis 863 

Catarrh 863 

Coryza 863 

Comedoes (small pimples) 722 

Symptoms, Treatment 723 

Conception (pregnancy) 677 

Conception, Prevention of (Wm. 

Goodell, M. D., reference) .... 18 
Why Is Prevention of Concep- 
tion Injurious to the Health of 
Women 61 

Confinement (See Maternity). 

Constipation, Acute 652 

Chronic in Children 652 

Definition 652 

Artificial Food 653 

Constipation from Paralysis of 

Intestines 654 

Affection of Nerve Centers 654 

Altered State of the Blood 655 

Mechanical Obstruction from 

Within 655 

Symptoms 656 

Diagnosis, Treatment 658, 660 

Constipation (in adults) 34 

Fecal Impaction 7$ 

Diagnosis. Treatment 244, 246 

Consumption 278 

Diagnosis, Treatment. .401, 402, 405 

Contusions of Joints 791 

Treatment 791 

Convulsions 281, 282 

Croup 713 

Croupous Rhinitis 713 

Diagnosis 713 

Treatment 714 

Chronic Rhinitis 715 

Diagnosis, Treatment 715 

Circulatory System 452 

Crying of Children 270 

Curvature of Spine 267 

Cystitis 190, 191, 192 

Treatment 193, 195 

Debility, in a New-born Child 314 

Symptoms, Treatment 314 

Decubitis in a New-born Child 738 

Symptoms, Treatment 73% 

Defective Nutrition in New-born 

Child . .304 

Causes of 304 

Defecation 34 

Disturbances of Functions 34 

Constipation 34 

Treatment 244, 246 

Dengue (fever) 598 

Symptoms, Treatment 599 

Dentition (teething) 380 

Eruntion of the Teeth 380 

Shedding of the Teeth 380 



Index. 



879 



Development 381 

Eruption of the Permanent 

Teeth 381 

Precocious Dentition 381 

Retarded Dentition 382 

Absence of Teeth 382 

Malformation of Teeth 383 

Disorders of Dentition (teeth). 384 

Diabetics in Children 291 

Diagnosis of Children's Diseases 

256, 273 

Diarrhea (simple) 613 

Symptoms, Treatment 613, 614 

Acute Dyspeptic Diarrhea 615 

Diagnosis from Cholera In- 
fantum 617 

Sudden Development of High 

Fever 618 

Treatment 618 

Feeding, clothing - 620 

Bathing 620 

Dietetic Treatment ...... 620 

General Rules of 620 

Resrular Feeding in 622 

Medical Treatment 623 

Diet after Weaning 359 

Resrulating the Time in Feeding 

Children 360 

Diarrhea from Improper Feed- 
ing . ••; .•• --363 

Constipation Corrected by Diet.. 363 

Digestive System 288 

Functional Disturbances 289 

Diphtheria 500 

Etiology 500 

Symptoms 502 

Severe Cases 502 

Diagnosis 502 

Treatment 504 

Nasal Hemorrhage 507 

Antitoxin Treatment 509 

Diseases of Nervous System 156 

Dependent upon Disorders of 

the Pelvic Organs 156 

Chorea 157 

Hysteria 158 

Treatment 159 

Headache 160 

Symptoms 160 

Treatment 161 

Dislocations, Causes of, Exciting 

Causes 797 

General Symptoms of Traumatic 

Dislocation 798 

Treatment 798, 799 

Dislocation of Collar-bone (clav- 
icle) 800 

Symptoms, Treatment 800 

Dislocation of Shoulder-blade (scap- 
ula) 800 

Treatment 801 

Dislocation of Shoulder-joint (hu- 
merus) 801 

Symptoms, Treatment .. 802, 803, 804 

Dislocation of the Elbow Joint .804 



Symptoms of Backward Dislo- 
cation 805 

Treatment of 805 

Dislocation of Both Bones Forward. 806 

Symptoms, Treatment 806 

Symptoms, Treatment of Out- 
ward Dislocation 806 

Symptoms, Treatment of Inward 
Dislocation 806 

Dislocation of the Ulna 806 

Treatment 806 

Dislocation of the Radius Forward. .806 
Symptoms, Treatment 807 

Dislocation of Head of Radius 807 

Symptoms, Treatment 807 

Dislocation of Wrist 808 

Symptoms, Treatment 808 

Dislocation of Ribs and Costal Car- 
tilages 808 

Diagnosis, Treatment 808 

Dislocation of Pelvis 808 

Treatment 809 

Dislocation of Hip- joint (femur) .. .810 
Symptoms, Treatment (Bryant) 

811, 812 
See Figures 812 

Dislocation of Knee 813 

Diagnosis, Treatment 813 

Dislocation of Head of Fibula (a 
long bone situated on the out- 
side of the leg) 813 

Diagnosis, Treatment 813 

Dislocation of Tibia (the largest 
bone in leg, situated on inside 

of fibula) 814 

Diagnosis, Treatment 814 

Displacements of Womb 98 

Causes of 105, 107, no 

Diagnosis 119 

Treatment 120 

Domestic Remedies That Should Be 

Kept in Ever}'- Household. .. .769 

Dropsy 273 

Dropsical Swelling 273 

Dy^smenorrhoea 31 

Causes of 31 

Symptoms, Treatment 144, 145 

Membranous 143 

Dysmenorrhea 139, 144, 145 

Congested and Inflammatory . . . 142 

Obstructed Dysmenorrhea 143 

Diagnosis 144 

Treatment 145 

Dyspeptic Diarrhea 615. 

Acute 615 

Diagnosis from Cholera Infan- 
tum 617 

Diagnosis 617 

Treatment 618 

General Rules for Feeding 622 

Feeding Dyspeptic Diarrhea 622 

Medical Treatment 622, 623 

Antiseptic Drugs 625 

Astringents (vegetable) 626 

Astringents (mineral) 626 



380 



Index. 



Stimulants 627 

Ear Troubles in Children 511 

Causes of 511 

Inflammation and Its Results. . .511 

Erythema 511 

Eczema 511 

Intertrigo 511 

Chafing 511 

Boxing the Ears 512 

Pulling the Ears 512 

Foreign Bodies in the Ears ....512 
Inflammation of Ear (otitis) .. .513 
Treatment 514 

Eczema . . . . 745-748 

Treatment 748-754 

Infantile 754, 757 

"Enlargements 32 

Enlargement of Abdomen 32 

External Genitals 32 

Enlargements of Uterus 32 

Disturbance of Functions 33 

Symptoms ^ 

Endometritis (inflammation inside of 

womb) 51 

Following Abortion 52, 55 

Septic Inflammation 56 

Symptoms 58 

Treatment 59 

Enteric, or Typhoid Fever 441 

(See Fever, Typhoid.) 

Enteritis, Chronic Membranous 640 

Symptoms 640 

Treatment 640, 641 

Ulcerative Enteritis 642 

Symptoms 642 

Treatment 642, 643 

Diphtheritic Enteritis 642 

Gangrenous Enteritis 644 

Erythema (rash) 728 

Diagnosis, Treatment 729, 730 

Chafing 729 

Erysipelas 548 

Symptoms 549 

Diagnosis, Treatment 552 

Female Urethra, Its Diseases 174 

Diagnosis 175 

Treatment 175 

Stricture of Neck of Bladder. . .176 

Treatment 177 

Vesico-Urethral Fissure 177 

Symptoms 177 

Urethrocele 177 

Diagnosis 178 

Urethral Dislocations 179 

Diagnosis, Treatment 179 

Fistula 180 

Urethral Tumors 180 

Caruncle 180 

Urethral Cysts 181 

Cancer of 181 

Treatment 181 

Fevers and Miasmatic Diseases . . . .421 

Definition 421 

Causes of Fever 422 

Stages and Types 425 



Symptoms, Treatment 429, 430 

Fever (break-bone fever; dengue).. 598 

Symptoms 599 

Treatment 600 

Fevers, Hay 864 

Etiology 864 

Symptoms 864 

Prognosis 865 

Treatment 865 

Fevers, Intermittent 583 

Fevers, Malarial 581 

Fever, Relapsing 479 

Symptoms 479 

Diagnosis 480 

Differential Diagnosis from 

Eruptive Fevers 480 

Treatment 480, 481 

Fever, Scarlet (see Scarlet Fever).. 491 

Fever, Simple (continued) 435 

Diagnosis 436 

Treatment 436 

Fever, Spotted, or 482 

Cerebro-Spinal Fever 482 

Definition 482 

Symptoms 482 

Commencement of Spinal Fever. 484 

Diagnosis 487 

Treatment 488 

Fever, Thermic, Sunstroke 437 

Symptoms 438 

Diagnosis 438 

Treatment 438 

Fever, Typhoid 441 

Symptoms 441 

Age, Predisposing Cause 442 

Exciting Cause 443 

First Stage 444 

Second Stage 446 

Third Stage 446 

Symptoms in Adults 447 

Principal Symptoms 450 

Digestive System in Typhoid. . . .454 

Diarrhea 454 

Hemorrhage from Bowels 455 

Delirium 456 

Menstruation at Puberty 457 

Rose Rash 457 

Complications of .458 

Diagnosis 459 

Typhoid, Remittent 460 

Treatment of Typhoid 462 

General Management of Patient. 463 

Cold Pack, Cold Bath 467 

Cold Affusion 468 

Collapse 472 

Convalescence 473 

Fever, Typhus 474 

Symptoms 475 

Diagnosis, Treatment 476, 478 

Fever, Yellow 593 

Symptoms 594 

Diagnosis 595 

Treatment 596, 597 

Fibroid Tumors of Womb 100 

Fistula of Anus 216 



Index. 



881 



Urethral Fistula 180 

Foetus, Diseases of 304 

Hereditary Diseases 305 

Syphilis 308 

Treatment 308 

Infectious Diseases 308 

Variola 309 

Scarlet Fever 309 

Typhoid Fever, etc 309 

Food and Food Preparation 816 

Classification 822 

Table of Composition of Some 

Common Foods 823 

Uses of Water in Body 832 

Use of Salt in Food 834 

Milk Diet ...836, 837 

Meat Diet 838 

Cereals and Other Starchy 

Foods 842 

Prepared Farinaceous Food for 

Infants 843 

Starchy Food for Children 846 

Vegetable Foods 846 

Fruits 847 

Fats and Oils 849 

Stimulants, Beverages 850 

Sick-room Dietary 852 

Cooking 852 

Fractures of Bones of Upper Ex- 

tremitv 770, 776 

Definition 770 

Causes of 770 

Symptoms 771 

Bryant's Diagnosis of Fracture. 771 
Treatment 773, 77^ 

Fracture of Clavicle (collar-bone) . . .775 
Symptoms, Treatment 77%, 776 

Fracture of Surgical Neck of Hu- 
merus 777 

Symptoms, Treatment 777 

Fracture of Upper Extremity, the 
Head and Surgical Neck of 

the Humerus 776, 777 

Symptoms 776, 777 

Treatment 776, 777' 

Fracture of Shaft of Humerus 777 

Treatment 778 

Fracture of Shaft of Ulna 778 

Treatment 778 

Fracture of Shaft of Radius 778 

Symptoms 779 

Treatment 779 

Fracture of Both Bones of Fore- 
arm 779 

Symptoms 779 

Treatment 779 

Fracture of Bones of Hand 779 

Symptoms. Treatment 780 

Fracture of Femur, Intra-capsular 

Fracture 781 

Symptoms, Diagnosis, Treatment 

781, 782 

Fracture of Shaft of Femur 785 

Diagnosis, Treatment (Bryant's) 

785, 786 
56 



Fracture of Bones of Leg 787 

Symptoms of 788 

Fracture of Both Bones of Leg 788 

Symptoms, Treatment 788 

Fracture of Beth Bones of Foot 789 

Symptoms, Treatment 789 

Functional Diseases of Womb 

(uterus) 124, 125 

Menstrual Disorders 124, 125 

Change of Life (menopause) 

125, 126 
Acute Suppression of Menses.. 131 

Treatment 133 

Menorrhagia (too much flowing) 

133 

Flowing between Periods 133 

Painful Menstruation (dysmen- 
orrhea) 139 

Furuncles (boils), see Boils... 730, 732 

General Diseases of Women 29 

Clinical History of Cases 29 

Kinds of Diseases 29 

Character of Pain 30 

General Treatment of Nervous Dis- 
orders of Female Puberty 418 

Gonorrhceal Vaginitis 38, 46 

Infectious Disease 43, 44 

Diagnosis, Treatment 46, 47 

Gravel in Urine 291 

Acid Urine in Children 37 

Hematocele 76 

Hay-fever 864 

Etiology 864 

Symptoms 864 

Prognosis 865 

Treatment 865 

Heart Disease 277, 287 

Haemorrhoids (piles) 217 

Diagnosis, Treatment 217, 221 

Herpes, zoster 741 

Shingles 741 

Symptoms 742 

Diagnosis 7 A 2 

Treatment 743 

Heredity (inherited) _ 3°5 

Diseases Transmitted 305 

Hygiene 617 

Hysterical Disorders. .390, 394, 396, 397 

Hyperidrosis (sweating) 726 

Treatment 7 2 7 

Hypertrophy cf Breasts 253 

Ichthyosis (harsh, dry, scaly skin).. 757 

Diagnosis 757 

Treatment 757 

Icterus (iaundice) 645 

Definition 645 

Symptoms .646 

Diagnosis 647 

Jaundice in Older Children 647 

Symptoms 647 

Diagnosis 648 

Treatment 649 

Infant Feeding, Weaning 329 

Superiority of Breast Feeding.. 329 
General Rules for Feeding. . , . .330 



882 



Index. 



Each Feeding 331 

Sterilizing Food 345 

Comparison of Woman's Milk 

with Cow's Milk 349 

Condensed Milk 350 

Nestle's Food 350 

Imperial Granum 350 

Mellin's Food 350 

Barley Water 350 

Biedert's Cream Mixture 350 

Mixture Recommended 351 

Cream Mixture 353 

Infantile Eczema 754 

Infantile Feeding 329 

Inflammation of Nose 521 

Treatment . . 521 

Inflammation of Female Genital Or- 
gans 37, 62 

Causes of 38 

Treatment 38, 39 

Inflammation of Vagina 40 

Due to Cold 41 

Diagnosis 42 

Treatment 43 

Inflammation Following Abortion 

and Labor 52 

Septic Inflammation 52 

Treatment 53 

Inflammation, Bladder 190, 191, 192 

Treatment 193, 195 

Inflammation of Ovaries (acute) .... 66 

Vaginal Inflammation 39 

Diphtheritic Vaginitis 41 

Abscesses of 41 

Acute Vaginitis 42 

Simple Inflammation of Vagina. 42 
Gonorrhceal Inflammation of the 

Vagina 43 

Treatment 44 

Inflammation of Vaeinal Walls, 

Deep Seated 46 

Treatment 46 

Inflammation of Womb 62 

Pelvic Inflammation 62 

Treatment 91 

Injuries to Bones 324 

Injuries 321 

Introductory 17 

Intermittent Fever 583 

Mild Form 583 

Pernicious Form 586 

(See Fevers.) 

Insanity 165 

Causes of 166 

Treatment 167 

Nymphomania 168, 169 

Sexual Feelings 168, 169 

Treatment 168, 169 

Perverted Sexual Appetite 169 

Dyspareunia 170 

Vaginismus 171 

Treatment 171 

Jaundice 645 

Symptoms 646 

Diagnosis 647 



Treatment 649 

Jaundice in Older Children 647 

Symptoms 647 

Diagnosis 648 

Catarrh of Bile Duct 650 

Treatment 651 

Kidneys 190 

Lateroversion 116 

Lateral Displacement of Womb. 116 

Leucorrhcea 31 

Vaginal Leucorrhcea 31 

Cervical Leucorrhcea 32 

Lice (head and body lice) 763 

Treatment 763 

Lithemia, Disturbances of the Liver. 651 

Treatment 651 

Liver 651 

Lying-in Room 682 

(See Maternity) 682 

Malaria 581 

Symptoms 583 

Intermittent Form 583 

Nervous System, see Fevers. 

Diagnosis, Treatment 588, 589 

Masturbation 141 

Maternity 674 

Hygiene, Management of Preg- 
nancy 677 

Diet 677 

Exercise 678 

Rest 678 

Clothing 678 

Bathing 679 

Local Treatment 679 

Mental Hygiene 680 

Management of Pregnancy 680 

The Lying-in Room 682 

The Nurse's Preparation of 682 

Preparation of Bed 683 

The Patient 683 

The Obstetric Bag 683 

Anaesthesia 684 

Examination during Labor 686 

Management First Stage of Labor 

687 
Management Second Stage of 

Labor 688 

Rupture of Membrane 689 

Obstetric Position 689 

Prevention of Injuries to Pelvic 

Floor 690 

Management of the Cord 692 

Delivery of the Trunk 693 

Ligation of Cord 693 

Management of Third Stage of 

Labor ...694,695 

Laceration of Floor or Perito- 
neum 606 

Toilet of the Patient 696 

Abdominal Binder 696 

After Pains 697 

Asepsis .697 

Posture 697 

Rest 698 

Ventilation 698 



Index. 



883 



Diet 698 

Retention of Urine 699 

Use of Catheter 699 

Evacuation of the Bowels 699 

Lactation 700 

Special Directions 701 

Regulation of Lying-in 702 

Ligation of Cord 703 

Bathing the Child 704 

Conjunctivitis in New-born ....704 

Dressing the Cord 705 

Dressing the Child 705 

Maternal Impressions 293, 294 

Through What Channel Are 
Impressions Made on the 
Mother ? 300, 302 

Measles 515 

Symptoms 515 

Stage of Eruption 516 

Complications 517 

Diagnosis 518 

Treatment 519 

Measles, German 521 

Symptoms 521 

Diagnosis 522 

Treatment 522 

Meningitis 482 

Symptoms 483 

Diagnosis 487 

Treatment 489 

Menorrhagia (flowing too much) . . .133 
Diagnosis 133 

Menstrual Disorders 124, 125 

Menstruation 125 

Acute Suppression 131 

Treatment 135 

Functional Diseases 124, 125 

Metritis (inflammation of womb) ... 48 

Symptoms 48 

Diagnosis 49 

Treatment 50, 51 

Metrorrhagia (flowing between 

monthly periods) 133 

Diagnosis 134 

Treatment 135 

Mumps 547 

Nasal Obstruction 706 

Effects of 706 

Ear Cough . . 710 

Treatment 711 

Nasal Catarrh 712 

Treatment 712 

Local Treatment 714 

General Treatment 714 

Nervous System 156 

Chorea 158 

Hysteria 158 

Diseases of Nervous System... 156 

Nettle Rash 739 

Nightmare, Causes of 283 

Neuralgic Dysmenorrhea 140 

Nursery Hygiene 369 

Ventilation 371 

Temperature of Room 373 

Toilet -.374 



Dress 375 

Outdoor Exercise 379 

Nursing of Sick Children 601 

The Sick Room 604 

Feeding 609 

Bathing 610 

Clothing 611 

Oedema in Children 27s 

Otologia (earache), as Indicated by 

Crying 386 

Redness and Swelling of the 
Gums 387 

Otitis (inflammation of the ear).... 513 
Treatment 513 

Ovarian Trouble 66 

Inflammation, Acute . . ^ 66 

Chronic Inflammation 67 

Pain (accompanying act of urinat- 
ing) 35 

Causes of 38 

Parasites (worms) 662 

Tapeworm 662 

Different Kinds 663 

Diagnosis 664 

Treatment . . .664, 665, 670, 672, 673 

Parotitis (mumps) 547 

Treatment 547 

Pelvic Abscess 74 

Symptoms, Treatment 74, 75 

Pelvic Inflammation 62 

Pemphigus (pimples) 744 

Treatment 244 

Peritonitis (different forms) 69 

Symptoms, Treatment 71, 74 

Pertussus (whooping-cough) 542 

Pimples 744 

Phlegmon (ulcer) 7^ 

Treatment j^ 

Pneumonia 285-287 

Poisons 675 

Animal Bites 675 

Reptile Bites 675 

Insect Stings 675 

Insect Bites 675 

Symptoms 676 

Treatment 676 

Poisons, Acids 676, 679 

Alkaloids 676, 679 

Treatments 676, 679 

Poisons, Vegetables 676, 679 

Mineral 676, 679 

Treatments 676, 679 

Domestic Remedies to be Kept 
Always in the House 679 

Polypi 181, 229 

Poultice, Flaxseed 859 

Bread and Milk 859 

Pregnancy, Management of 677 

Prevention of Conception 18, 23, 61 

Injuries of 18 23, 61 

Proctitis (inflammation of mucous 

membrane of the rectum) . . .210 
Treatment 211 

Prolapsis (falling) 116 

Of Womb and Bowels 232 



884 



Index. 



v 



Pruritis (itching of anus) 208 

Treatment 208 

Puberty; Its Pathology and Hygiene. 390 
Circumstances Affecting the Ev- 
olution of Puberty 390 

Period of Establishment in Fe- 
males 391 

Period of in Males 392 

Premature Puberty in Males ...393 

Diseases of Puberty 393 

Special Disorders in Female ....394 

Hysterical Disorders 394 

Hysterical Insanity 396 

Hysterical Epilepsy 396 

Hysterical 1 ranee 396 

l - Hysterical Paralysis 397 

Menstrual Disorders 398 

Dysmenorrhea 398 

Chlorosis, as Green Sickness ...399 

Green Sickness 399 

Treatment 400 

Consumption and strumous Dis- 
orders of Puberty 400 

Acute Form Tuberculosis or 

Consumption 401 

Treatment 402 

Early Stages of .Disease in a Dry 

Climate 405 

General Hygiene and Culture of 

Puberty 411 

Mental Training 412 

First Year of Life 413 

111 Results of Sexual Precocity. 414 

Abuse of Alcohol 415 

Abuse of Tobacco 415 

Special Hygiene 416 

Culture of Female Puberty: Its 

Practical Importance 416 

Influence of Dress 417 

Defects of Clothing 418 

General Treatment of Nervous 
Disorders of Female Puberty. 418 

Boys at the Age of Puberty 419 

Pulmonary and Cardiac System 283 

Pulse in Children 270 

Rectum Diseases 204 

Anatomy 204 

Injuries of Rectum 206 

Diagnosis 206 

Foreign Eodies in 207 

Symptoms 207 

Treatment 208 

Pruritis of Anus 208 

Treatment 208 

Fissure of Anus 209 

Symptoms, Treatment 209 

Proctitis 210 

Symptoms 210 

Treatment 210 

Abscess of Rectum 211 

After Treatment 212 

Fistula 213, 214 

Treatment 215 

Recto- Vaginal Fistula 216 

Symptoms 216 



Diagnosis 216 

Treatment 216 

Piles 217 

External Piles 217 

Symptoms 219 

Treatment 219, 220, 221 

Internal Piles 222 

Arterial Piles 222 

Venous Piles 223 

Capillary Piles 223 

Treatment 224 

Difference between Arterial and 

Venous Piles .225 

Treatment 226 

Soft Variety 230 

Diagnosis 230 

Treatment 230 

Polypoid Growth of Rectum . . .231 

Treatment 231 

Warts of 231 

Prolapsus of Rectum 232 

Diagnosis 233 

Treatment 233 

Hernial Sac in Prolapsus cf 

Rectum 234 

Treatment 235 

Treatment in Adults 236 

Ulcers and Strictures of Rectum. 238 

Varieties of Ulceration 238 

Svmptoms 238 

Palliative Treatment 240, 241 

Stricture of Rectum without 

Laceration 242 

Symptoms 243 

Constipation 244 

Symptoms 245 

Diagnosis 246 

Treatment 246, 248, 249 

Relapsing Fever 479 

(See Fevers.) 

Retroversion of Womb 108 

(See Displacements.) 

Rheumatism 554 

Acute Articular 556 

Complication of 558 

Diagnosis 561 

Treatment 562, 567 

Chronic Rheumatism 567 

Gonorrhceal Form 568 

Symptoms, Treatment 569 

Chronic Articular Form 569 

Diagnosis, Treatment 570 

Heart Disease in Rheumatism. . .558 

Rhinitis (inflammation of nose) 521 

Treatment 521 

Rhinitis ' 863 

Ringworm '..... 760 

Rupture of Perineum 689 

Rubella (German measles) 522 

Rubeola (measles) 521 

See Measles 521 

Salpinx (a tube) 71 

Salpingitis (inflammation of the 

tube) 64 

Salt-rheum 7^0 

Scabies 762 



Index. 



885 



A Cutaneous Disease 762 

Diagnosis 762 

Treatment 763 

Scrlet Fever 491 

Prevention of 491 

Incubation Period 492 

Symptoms 493 

Mali.snant Form 495 

Complication of 496 

Diagnosis 497 

Treatment 497, 498 

Scrofulous Disorders 401 

Seborrhoea (scalp affection) 721 

Diagnosis 721 

Treatment , 721 

Shingles 741 

Skin Diseases 720 

Symptoms 721 

Diagnosis 722 

Treatment 722 

Sleep Walking 283 

Smallpox ..' 525 

Symptoms 526 

Diagnosis 526 

Treatment 526 

Somnambulism 283 

Spasms in Young Girls 145 

Use of Nitro-glycerine 145 

Spine, Curvature of 267 

Spine, Irritation of Tip End... 163, 164 

Diagnosis 163, 164 

Sprains, Wounds, Injuries to Joints. 791 

Treatment 791, 792 

Stomatitis 289 

Apthous (thrush) 289 

Stenosis, Flexion Causes of Ster- 
ility 60 

Treatment by Electricity 61 

Sterility 1/18, 149 

Treatment by Galvanic Current 

of Electricity 149 

Sterility 152 

Fault May Be in Husband 152 

St. Vitus Dance (chorea) . .157, 158, 159 

Sweating 726 

Syncope, of New-born Child 319 

Treatment 319 

Syphilis, Infectious Disease 305 

Symptoms, Treatment 306 

Tinea (a gnawing worm) 759 

Tinea Favosa 759 

Treatment 760 

Tonsillitis 866 

Acute Tonsillitis 866 

Acute Superficial Tonsillitis ..866 
Course, Duration, and Termina- 
tion 866 

Treatment 867 

Quinsy 866 

Thrush (Oidium Albicans) 290 

Trichina (parasite) 461 

Diagnosis, Treatment 461 

Tubercular Meningitis 281 

Tuberculosis (consumption) 398 

Diagnosis, Treatment 399 



Tuberculosis and Strumous Disor- 
ders of Puberty 400, 401 

Treatment 404, 406 

Typhoid Fever 441 

See Fevers 441 

Typhus Fever 474 

See Fevers 474 

Ulcers 734 

Treatment 734 

Ureters (a canal which conveys 

urine from kidneys to bladder) 46 
Treatment 47 

Urethral Disease 174 

Urethral Stricture 177 

Treatment 177 

Urethritis (inflammation of neck of 

the bladder) 174 

Stricture of Neck of Bladder. . .176 

Diagnosis 177 

Treatment 177 

Urethral fissure 177 

Symptoms 177 

Fistula 177 

Urethral Tumors 180 

Caruncle 180 

Urethral Cysts 181 

Cancer 181 

Treatment 181, 182 

Urticaria 739 

Nettle-rash (salt-rheum) 739 

Different Kinds of Nettle-rash. 740 

Diagnosis 740 

Treatment 740 

Uterus (womb) 116 

Diseases of 232 

Vagina (a canal) 40 

Diseases of 41 

Diagnosis 41 

Treatment 41 

Vaginitis, Gonorrheal 38 

Diagnosis, Treatment 

, r . , . ' 39, 43, 44, 151 

Varices (varicose veins) 181 

Diagnosis 181 

Treatment 181 

Variola (smallpox) 525 

Symptoms 525 

Treatment 525 

Varicella (chickenpox) 525 

Symptoms 525 

Treatment 525 

Vomiting, Significance of in Children 

284 

Voice, Loss of 280 

Vulva 38 

Diseases of 38 « 

Treatment 39 

Weaning (see Infant Weaning; 

Feeding) 329 

Wet-nurse 355 

Care in Selecting 356 

Wetting Bed at Night 292 

William Goodell, M. D., Reference 

to Prevention of Conception.. 18 
Why Prevention of Conception 
Injurious to Health of Women 2^ 



Jan. 2 4. IPOS 



Index 



/?C 3 2.J 

c 



Warning Word upon Prevention 

of Conception 61 

Whooping-cough 539, 542 

Symptoms, Treatment 542, 545 

Womb (uterus) 116 

Diseases of, Falling of, Bending 
Backward, Bendinc Forward, 
Inflammation of, Tumors of, 

Diagnosis, Treatment 98-232 

Injuries of 232 

Diagnosis 233 

Treatment 233 



L,'i 7 S3 

Worms (parasites) ■ . . '. . . .662 

Different Kinds of Worms 663 

Diagnosis, 1 reatment 664 

Wounds of Joints 795 

Treatment 795 

Yellow Fever 593 

See Fevers 594 

Diagnosis 795 

Treatment 796, 797 

Yellow- jacket, Stings of 765 

Treatment a . . .765' 

Other Stings and Bites 765, 766 



